For Residents

Isotretinoin is one of the most highly regulated dermatologic medications on the market. The main reason for regulation through the US Food and Drug Administration (FDA)–managed iPLEDGE Risk Evaluation and Mitigation Strategy (REMS) is to minimize the drug’s teratogenic potential, as isotretinoin can cause profound birth defects. The program originally categorized patients into 1 of 3 categories: (1) females of reproductive potential, (2) females not of reproductive potential, and (3) males. Unless the patient commits to abstinence, the program required female patients of childbearing potential to be on 2 forms of birth control and undergo regular pregnancy testing before obtaining refills. Over the last few years, the American Academy of Dermatology Association (AADA) has been advocating for changes to the iPLEDGE system. Proposed changes have included decreasing attestation frequency for patients who cannot get pregnant, increasing contraception counseling and options, and changing enrollment guidelines to encompass all gender and sexual minorities. As of December 13, 2021, the iPLEDGE system changed enrollment categories to reflect the AADA’s wishes and rolled out gender-neutral categories for enrollment in iPLEDGE. This change will simplify and enhance patients’ experience when starting isotretinoin.

Developing Inclusive iPLEDGE Categories

In recent years, dermatologists and patients have viewed these strict gender-based categories as limiting and problematic, especially for their transgender patients and female patients of childbearing potential who exclusively engage in intercourse with cisgender females. The United States has more than 10 million LGBTQIA+ citizens and an estimated 1.4 million adults who identify as transgender individuals, rendering the previously established gender-binary iPLEDGE categories outdated.^1,2

As a result, over the last few years, dermatologists, LGBTQIA+ allies, and patients have urged the FDA to create a gender-neutral registration process for iPLEDGE. With support from the AADA, the new modifications were approved for implementation and include 2 risk categories: (1) people who can get pregnant and (2) people who cannot get pregnant.³

As exciting as these changes are for the future of dermatologic practice, the actual transition to the new iPLEDGE system was described as a “failure, chaotic, and a disaster” due to additional changes made at the same time.⁴ The iPLEDGE system was switched to a new website administered by a different vendor and required providers to confirm each patient online by December 13, 2021. In addition, the new system required pharmacists to obtain risk management authorization via the iPLEDGE REMS website or by calling the iPLEDGE REMS center before dispensing isotretinoin. This overhaul did not work as planned, as the new website was constantly down and it was nearly impossible to reach a contact over the telephone. The complications resulted in major disruptions and delayed prescriptions for thousands of patients nationwide as well as a great disruption in workflow for physicians and pharmacists. The AADA subsequently met with the Isotretinoin Products Manufacturers Group to create workable solutions for these issues.

On January 14, 2022, the FDA posted updates regarding access to the iPLEDGE system. They have worked with the Isotretinoin Products Manufacturers Group to create workable solutions for patients and physicians while transferring the patients’ information to the new database. Their solution includes allowing physicians to send patients login links through their email to access their account instead of waiting for the call center. The majority of iPLEDGE users now have access to their accounts without issues, and the gender-neutral guidelines have been in place since the original change.

Impact of iPLEDGE Categories on Transgender Patients

These changes specifically will improve the experience of transgender men and cisgender women who are at no risk for pregnancy and could be subjected to monthly pregnancy testing when it is not medically necessary.

Consider the following patient scenario. A transgender man presents to your dermatology office seeking treatment of severe nodulocystic acne. He was placed on hormonal replacement therapy with exogenous testosterone—injections, oral pills, topical gel, topical patches, or subdermal pellets—to achieve secondary sex characteristics and promote gender congruence. The patient mentions he has been amenorrheic for several months now. He has tried many topical acne treatments as well as oral antibiotics without much benefit and is now interested in enrolling in iPLEDGE to obtain isotretinoin. With the prior iPLEDGE registration packets, how would this transgender man be classified? As a female with childbearing potential due to his retained ovaries and uterus? What if he did not endorse engaging in sexual intercourse that could result in pregnancy?

Transgender patients have unique and unmet needs that often are overlooked and prevent them from equitable, gender-affirming health care. For example, in a prospective study following 20 transgender men starting hormone replacement therapy, the percentage of patients with facial acne increased from 35% to 82% after 6 months of therapy.⁵ In addition, the increased psychosocial burden of acne may be especially difficult in these patients, as they already report higher rates of depression and suicidal ideation compared with their heterosexual cisgender peers.⁴ Further, the primary patient populations receiving isotretinoin typically are adolescents and young adults who are undergoing major physical, mental, and hormonal changes. Self-discovery and self-actualization develop over time, and our role as physicians is to advocate for all aspects of our patients’ health and eliminate barriers to optimal care.

Inclusive Language in iPLEDGE Categories

It is important to streamline access to care for all patients, and gender-affirming, culturally sensitive language is essential to building trust and understanding between patients and providers. Howa Yeung, MD, MSc, a dermatologist at Emory University (Atlanta, Georgia) who advocated for gender-neutral iPLEDGE registration, welcomes the change and stated it “will make my job easier. I no longer have to struggle between respecting the patient’s gender identity and providing medically necessary care for patients with severe acne.”³

Sanchez et al⁶ provided a list of structured questions providers can ask their patients to assess their risk regarding pregnancy: (1) Do you have a uterus and/or ovaries?, (2) Are you engaging in sexual intercourse with a person who has a penis?, and (3) If yes to these questions, what form(s) of birth control are you using? Providers should preface these questions with the following statement: “It is important that I ask these questions to assess your risk for becoming pregnant on this medication because isotretinoin can cause very serious birth defects.” It is important to review these questions and practice asking them so residents can operate from the same place of openness and understanding when caring for their patients.

Final Thoughts

The landscape of isotretinoin prescribing currently is changing on a day-to-day basis. As residents, it is important we stay up to date with the changes regarding our regularly dispensed medications. The main modification made to the iPLEDGE REMS system was switching the risk categories from 3 (females who can get pregnant, females who cannot get pregnant, males) to 2 (people who can get pregnant, people who cannot get pregnant). This change will make registration for iPLEDGE less complex and more inclusive for all patients. It is important for residents to stay at the forefront of these patient health issues and barriers to equal care, and this change represents a step in the right direction.

Isotretinoin is one of the most highly regulated dermatologic medications on the market. The main reason for regulation through the US Food and Drug Administration (FDA)–managed iPLEDGE Risk Evaluation and Mitigation Strategy (REMS) is to minimize the drug’s teratogenic potential, as isotretinoin can cause profound birth defects. The program originally categorized patients into 1 of 3 categories: (1) females of reproductive potential, (2) females not of reproductive potential, and (3) males. Unless the patient commits to abstinence, the program required female patients of childbearing potential to be on 2 forms of birth control and undergo regular pregnancy testing before obtaining refills. Over the last few years, the American Academy of Dermatology Association (AADA) has been advocating for changes to the iPLEDGE system. Proposed changes have included decreasing attestation frequency for patients who cannot get pregnant, increasing contraception counseling and options, and changing enrollment guidelines to encompass all gender and sexual minorities. As of December 13, 2021, the iPLEDGE system changed enrollment categories to reflect the AADA’s wishes and rolled out gender-neutral categories for enrollment in iPLEDGE. This change will simplify and enhance patients’ experience when starting isotretinoin.

Developing Inclusive iPLEDGE Categories

In recent years, dermatologists and patients have viewed these strict gender-based categories as limiting and problematic, especially for their transgender patients and female patients of childbearing potential who exclusively engage in intercourse with cisgender females. The United States has more than 10 million LGBTQIA+ citizens and an estimated 1.4 million adults who identify as transgender individuals, rendering the previously established gender-binary iPLEDGE categories outdated.^1,2

As a result, over the last few years, dermatologists, LGBTQIA+ allies, and patients have urged the FDA to create a gender-neutral registration process for iPLEDGE. With support from the AADA, the new modifications were approved for implementation and include 2 risk categories: (1) people who can get pregnant and (2) people who cannot get pregnant.³

As exciting as these changes are for the future of dermatologic practice, the actual transition to the new iPLEDGE system was described as a “failure, chaotic, and a disaster” due to additional changes made at the same time.⁴ The iPLEDGE system was switched to a new website administered by a different vendor and required providers to confirm each patient online by December 13, 2021. In addition, the new system required pharmacists to obtain risk management authorization via the iPLEDGE REMS website or by calling the iPLEDGE REMS center before dispensing isotretinoin. This overhaul did not work as planned, as the new website was constantly down and it was nearly impossible to reach a contact over the telephone. The complications resulted in major disruptions and delayed prescriptions for thousands of patients nationwide as well as a great disruption in workflow for physicians and pharmacists. The AADA subsequently met with the Isotretinoin Products Manufacturers Group to create workable solutions for these issues.

On January 14, 2022, the FDA posted updates regarding access to the iPLEDGE system. They have worked with the Isotretinoin Products Manufacturers Group to create workable solutions for patients and physicians while transferring the patients’ information to the new database. Their solution includes allowing physicians to send patients login links through their email to access their account instead of waiting for the call center. The majority of iPLEDGE users now have access to their accounts without issues, and the gender-neutral guidelines have been in place since the original change.

Impact of iPLEDGE Categories on Transgender Patients

These changes specifically will improve the experience of transgender men and cisgender women who are at no risk for pregnancy and could be subjected to monthly pregnancy testing when it is not medically necessary.

Consider the following patient scenario. A transgender man presents to your dermatology office seeking treatment of severe nodulocystic acne. He was placed on hormonal replacement therapy with exogenous testosterone—injections, oral pills, topical gel, topical patches, or subdermal pellets—to achieve secondary sex characteristics and promote gender congruence. The patient mentions he has been amenorrheic for several months now. He has tried many topical acne treatments as well as oral antibiotics without much benefit and is now interested in enrolling in iPLEDGE to obtain isotretinoin. With the prior iPLEDGE registration packets, how would this transgender man be classified? As a female with childbearing potential due to his retained ovaries and uterus? What if he did not endorse engaging in sexual intercourse that could result in pregnancy?

Transgender patients have unique and unmet needs that often are overlooked and prevent them from equitable, gender-affirming health care. For example, in a prospective study following 20 transgender men starting hormone replacement therapy, the percentage of patients with facial acne increased from 35% to 82% after 6 months of therapy.⁵ In addition, the increased psychosocial burden of acne may be especially difficult in these patients, as they already report higher rates of depression and suicidal ideation compared with their heterosexual cisgender peers.⁴ Further, the primary patient populations receiving isotretinoin typically are adolescents and young adults who are undergoing major physical, mental, and hormonal changes. Self-discovery and self-actualization develop over time, and our role as physicians is to advocate for all aspects of our patients’ health and eliminate barriers to optimal care.

Inclusive Language in iPLEDGE Categories

It is important to streamline access to care for all patients, and gender-affirming, culturally sensitive language is essential to building trust and understanding between patients and providers. Howa Yeung, MD, MSc, a dermatologist at Emory University (Atlanta, Georgia) who advocated for gender-neutral iPLEDGE registration, welcomes the change and stated it “will make my job easier. I no longer have to struggle between respecting the patient’s gender identity and providing medically necessary care for patients with severe acne.”³

Sanchez et al⁶ provided a list of structured questions providers can ask their patients to assess their risk regarding pregnancy: (1) Do you have a uterus and/or ovaries?, (2) Are you engaging in sexual intercourse with a person who has a penis?, and (3) If yes to these questions, what form(s) of birth control are you using? Providers should preface these questions with the following statement: “It is important that I ask these questions to assess your risk for becoming pregnant on this medication because isotretinoin can cause very serious birth defects.” It is important to review these questions and practice asking them so residents can operate from the same place of openness and understanding when caring for their patients.

Final Thoughts

The landscape of isotretinoin prescribing currently is changing on a day-to-day basis. As residents, it is important we stay up to date with the changes regarding our regularly dispensed medications. The main modification made to the iPLEDGE REMS system was switching the risk categories from 3 (females who can get pregnant, females who cannot get pregnant, males) to 2 (people who can get pregnant, people who cannot get pregnant). This change will make registration for iPLEDGE less complex and more inclusive for all patients. It is important for residents to stay at the forefront of these patient health issues and barriers to equal care, and this change represents a step in the right direction.

Isotretinoin is one of the most highly regulated dermatologic medications on the market. The main reason for regulation through the US Food and Drug Administration (FDA)–managed iPLEDGE Risk Evaluation and Mitigation Strategy (REMS) is to minimize the drug’s teratogenic potential, as isotretinoin can cause profound birth defects. The program originally categorized patients into 1 of 3 categories: (1) females of reproductive potential, (2) females not of reproductive potential, and (3) males. Unless the patient commits to abstinence, the program required female patients of childbearing potential to be on 2 forms of birth control and undergo regular pregnancy testing before obtaining refills. Over the last few years, the American Academy of Dermatology Association (AADA) has been advocating for changes to the iPLEDGE system. Proposed changes have included decreasing attestation frequency for patients who cannot get pregnant, increasing contraception counseling and options, and changing enrollment guidelines to encompass all gender and sexual minorities. As of December 13, 2021, the iPLEDGE system changed enrollment categories to reflect the AADA’s wishes and rolled out gender-neutral categories for enrollment in iPLEDGE. This change will simplify and enhance patients’ experience when starting isotretinoin.

Developing Inclusive iPLEDGE Categories

In recent years, dermatologists and patients have viewed these strict gender-based categories as limiting and problematic, especially for their transgender patients and female patients of childbearing potential who exclusively engage in intercourse with cisgender females. The United States has more than 10 million LGBTQIA+ citizens and an estimated 1.4 million adults who identify as transgender individuals, rendering the previously established gender-binary iPLEDGE categories outdated.^1,2

As a result, over the last few years, dermatologists, LGBTQIA+ allies, and patients have urged the FDA to create a gender-neutral registration process for iPLEDGE. With support from the AADA, the new modifications were approved for implementation and include 2 risk categories: (1) people who can get pregnant and (2) people who cannot get pregnant.³

As exciting as these changes are for the future of dermatologic practice, the actual transition to the new iPLEDGE system was described as a “failure, chaotic, and a disaster” due to additional changes made at the same time.⁴ The iPLEDGE system was switched to a new website administered by a different vendor and required providers to confirm each patient online by December 13, 2021. In addition, the new system required pharmacists to obtain risk management authorization via the iPLEDGE REMS website or by calling the iPLEDGE REMS center before dispensing isotretinoin. This overhaul did not work as planned, as the new website was constantly down and it was nearly impossible to reach a contact over the telephone. The complications resulted in major disruptions and delayed prescriptions for thousands of patients nationwide as well as a great disruption in workflow for physicians and pharmacists. The AADA subsequently met with the Isotretinoin Products Manufacturers Group to create workable solutions for these issues.

On January 14, 2022, the FDA posted updates regarding access to the iPLEDGE system. They have worked with the Isotretinoin Products Manufacturers Group to create workable solutions for patients and physicians while transferring the patients’ information to the new database. Their solution includes allowing physicians to send patients login links through their email to access their account instead of waiting for the call center. The majority of iPLEDGE users now have access to their accounts without issues, and the gender-neutral guidelines have been in place since the original change.

Impact of iPLEDGE Categories on Transgender Patients

These changes specifically will improve the experience of transgender men and cisgender women who are at no risk for pregnancy and could be subjected to monthly pregnancy testing when it is not medically necessary.

Consider the following patient scenario. A transgender man presents to your dermatology office seeking treatment of severe nodulocystic acne. He was placed on hormonal replacement therapy with exogenous testosterone—injections, oral pills, topical gel, topical patches, or subdermal pellets—to achieve secondary sex characteristics and promote gender congruence. The patient mentions he has been amenorrheic for several months now. He has tried many topical acne treatments as well as oral antibiotics without much benefit and is now interested in enrolling in iPLEDGE to obtain isotretinoin. With the prior iPLEDGE registration packets, how would this transgender man be classified? As a female with childbearing potential due to his retained ovaries and uterus? What if he did not endorse engaging in sexual intercourse that could result in pregnancy?

Transgender patients have unique and unmet needs that often are overlooked and prevent them from equitable, gender-affirming health care. For example, in a prospective study following 20 transgender men starting hormone replacement therapy, the percentage of patients with facial acne increased from 35% to 82% after 6 months of therapy.⁵ In addition, the increased psychosocial burden of acne may be especially difficult in these patients, as they already report higher rates of depression and suicidal ideation compared with their heterosexual cisgender peers.⁴ Further, the primary patient populations receiving isotretinoin typically are adolescents and young adults who are undergoing major physical, mental, and hormonal changes. Self-discovery and self-actualization develop over time, and our role as physicians is to advocate for all aspects of our patients’ health and eliminate barriers to optimal care.

Inclusive Language in iPLEDGE Categories

It is important to streamline access to care for all patients, and gender-affirming, culturally sensitive language is essential to building trust and understanding between patients and providers. Howa Yeung, MD, MSc, a dermatologist at Emory University (Atlanta, Georgia) who advocated for gender-neutral iPLEDGE registration, welcomes the change and stated it “will make my job easier. I no longer have to struggle between respecting the patient’s gender identity and providing medically necessary care for patients with severe acne.”³

Sanchez et al⁶ provided a list of structured questions providers can ask their patients to assess their risk regarding pregnancy: (1) Do you have a uterus and/or ovaries?, (2) Are you engaging in sexual intercourse with a person who has a penis?, and (3) If yes to these questions, what form(s) of birth control are you using? Providers should preface these questions with the following statement: “It is important that I ask these questions to assess your risk for becoming pregnant on this medication because isotretinoin can cause very serious birth defects.” It is important to review these questions and practice asking them so residents can operate from the same place of openness and understanding when caring for their patients.

Final Thoughts

The landscape of isotretinoin prescribing currently is changing on a day-to-day basis. As residents, it is important we stay up to date with the changes regarding our regularly dispensed medications. The main modification made to the iPLEDGE REMS system was switching the risk categories from 3 (females who can get pregnant, females who cannot get pregnant, males) to 2 (people who can get pregnant, people who cannot get pregnant). This change will make registration for iPLEDGE less complex and more inclusive for all patients. It is important for residents to stay at the forefront of these patient health issues and barriers to equal care, and this change represents a step in the right direction.

The COVID-19 pandemic largely altered the practice of medicine, including a rapid expansion of telemedicine following the March 2020 World Health Organization guidelines for social distancing, which recommended suspension of all nonurgent in-person visits.¹ Expectedly, COVID-related urgent care visits initially comprised the bulk of the new telemedicine wave: NYU Langone Health (New York, New York), for example, saw a 683% increase in virtual visits between March and April 2020, most (55.3%) of which were for respiratory concerns. In-person visits, on the other hand, concurrently fell by more than 80%. Interestingly, nonurgent ambulatory care specialties also saw a considerable uptick in virtual encounters, from less than 50 visits in a typical day to an average of 7000 in a 10-day stretch.²

As a largely ambulatory specialty that relies on visual examination, dermatology was no exception to the swing toward telemedicine, or teledermatology (TD). Before the COVID-19 pandemic, 14.1% (82 of 582 respondents) of practicing US dermatologists reported having used teledermatology, compared to 96.9% (572/591) during the pandemic.³ Even at my home institution (Massachusetts General Hospital [Boston, Massachusetts] and its 12 affiliated dermatology clinics), the number of in-person visits in April 2020 (n=67) was less than 1% of that in April 2019 (n=7919), whereas there was a total of 1564 virtual visits in April 2020 compared to zero the year prior. Virtual provider-to-provider consults (e-consultations) also saw an increase of more than 20%, suggesting that dermatology’s avid adoption of TD also had improved the perceived accessibility of our specialty.⁴

The adoption and adaptation of TD are projected to continue to grow rapidly across the globe, as digitalization has enhanced access without increasing costs, shortened wait times, and even created opportunities for primary care providers based in rural or overseas locations to learn the diagnosis and treatment of skin disease.⁵ Residents and fellows should be privy to the nuances of training and practicing in this digital era, as our careers inevitably will involve some facet of TD.

The Art of Medicine

Touch, a sense that perhaps ranks second to sight in dermatology, is absent in TD. In either synchronous (live-interactive, face video visits) or asynchronous (store-and-forward, where digital photographs and clinical information sent by patients or referring physicians are assessed at a later time) TD, the skin cannot be rubbed for texture, pinched for thickness, or pushed for blanching. Instead, all we have is vision. Irwin Braverman, MD, Professor Emeritus of Dermatology at Yale University (New Haven, Connecticut), alongside Jacqueline Dolev, MD, dermatologist and Yale graduate, and Linda Friedlaender, curator at the Yale Center for British Art, founded an observational skills workshop in which trainees learn to observe and describe the paintings housed in the museum, noting all memorable details: the color of the sky, the actions of the animals, and the facial expressions of the people. A study of 90 participants over a 2-year period found that following the workshop, the ability to identify key diagnostic details from clinical photography improved by more than 10%.⁶ Other studies also utilizing fine art as a medical training tool to improve “visual literacy” saw similarly increased sophistication in the description of clinical imagery, which translated to better diagnostic acumen.⁷ Confined to video and photographs, TD necessitates trainees and practicing dermatologists to be excellent visual diagnosticians. Although surveyed dermatologists believe TD is presently appropriate for acne, benign lesions, or follow-up appointments,³ conditions for which patients have been examined via TD have included drug eruptions, premalignant or malignant neoplasms, infections, and papulosquamous or inflammatory dermatoses.⁸ At the very least, clinicians should be versed in identifying those conditions that require in-person evaluation, as patients cannot be held responsible to distinguish which situations can and cannot be addressed virtually.

Issues of Patient-Physician Confidentiality

Teledermatology is not without its shortcomings; critics have noted diagnostic challenges with poor quality photographs or videos, inability to perform total-body skin examinations, and socioeconomic limitations due to broadband availability and speed.^5,9 Although most of these shortcomings are outside of our control, a key challenge within the purview of the provider is the protection of patient privacy.

Much of the salient concerns regarding patient-physician confidentiality involve asynchronous TD, where store-and-forward data sharing allows physicians to download patient photographs or information onto their personal email or smartphones.¹⁰ Although some hospital systems provide encryption software or hospital-sponsored devices to ensure security, physicians may opt to use their personal phones or laptops out of convenience or to save time.^10,11 One study found that less than 30% of smartphone users choose to activate user authentication on their devices, even ones as simple as a passphrase.¹¹ The digital exchange of information thus poses an immense risk for compromising protected health information (PHI), as personal devices can be easily lost, stolen, or hacked. Indeed, in 2015, more than 113 million individuals were affected by a breach of PHI, the majority over hacked network servers.¹² With the growing diversity of mediums through which PHI is exchanged, such as videoconferencing and instant messaging, the potential medicolegal risks of information breach continue to climb. The US Department of Health & Human Services urges health care providers to uphold best practices for security, including encrypting data, updating all software including antivirus software, using multifactor authentication, and following local cybersecurity regulations or recommendations.¹³ For synchronous TD, suggested best practices include utilizing headphones during live appointments, avoiding public wireless networks, and ensuring the provider and patient both scan the room with their device’s camera before the start of the visit.¹⁴

On the Horizon of Teledermatology

What can we expect in the coming years? Increased utilization of telemedicine will translate into data that will help address questions surrounding safety, diagnostic accuracy, privacy, and accessibility. One aspect of TD in need of clarity is a guideline on payment and reimbursement, and whether TD can continue to be financially attractive to providers. Starting in 2020, the Centers for Medicare & Medicaid Services removed geographic restrictions for reimbursement of telemedicine visits, enabling even urban-residing patients to enjoy the convenience of TD. This followed a prior relaxation of restrictions, where even prerecorded patient information became eligible for Medicare reimbursement.⁹ However, as virtual visits tend to be shorter with fewer diagnostic services compared to in-person visits, the reimbursement structure of TD must be nuanced, which is the subject of ongoing study and modification in the wake of the COVID-19 pandemic.¹⁵

Another point to consider is the explosion of direct-to-consumer TD, which allows patients to receive virtual dermatologic care or prescription medication without a pre-established relationship with any physician. In 2017, there were 22 direct-to-consumer TD services available to US patients in 45 states, 16 (73%) of which provided dermatologic care for any concern while 6 (27%) were limited to acne or antiaging and were largely prescription oriented. Orchestrated mostly by the for-profit private sector, direct-to-consumer companies are poorly regulated and have raised concerns over questionable practices, such as the use of non–US board-certified physicians, exorbitant fees, and failure to disclose medication side effects.¹⁶ A study of 16 direct-to-consumer telemedicine sites found substantial discordance in the suggested management of the same patient, and many of the services relied heavily on patient-provided self-diagnoses, such as a case where psoriasis medication was dispensed for a psoriasis patient who submitted a photograph of his syphilitic rash.¹⁷ Despite these problems, consumers show a willingness to pay out of pocket to access these services for their shorter waiting times and convenience.¹⁸ Hence, we must learn to ask about direct-to-consumer service use when obtaining a thorough history and be open to counseling our patients on the proper use and potential risks of direct-to-consumer TD.

Final Thoughts

The telemedicine industry is expected to reach more than $130 billion by 2025, with more than 90% of surveyed health care executives planning for the adoption and incorporation of telemedicine into their business models.¹⁹ The COVID-19 pandemic was an impetus for an exponential adoption of TD, and it would behoove current residents to realize that the practice of dermatology will continue to be increasingly digitalized within the coming years. Whether through formal training or self-assessment, we must strive to grow as proficient virtual dermatologists while upholding professionalism, patient safety, and health information privacy.

The COVID-19 pandemic largely altered the practice of medicine, including a rapid expansion of telemedicine following the March 2020 World Health Organization guidelines for social distancing, which recommended suspension of all nonurgent in-person visits.¹ Expectedly, COVID-related urgent care visits initially comprised the bulk of the new telemedicine wave: NYU Langone Health (New York, New York), for example, saw a 683% increase in virtual visits between March and April 2020, most (55.3%) of which were for respiratory concerns. In-person visits, on the other hand, concurrently fell by more than 80%. Interestingly, nonurgent ambulatory care specialties also saw a considerable uptick in virtual encounters, from less than 50 visits in a typical day to an average of 7000 in a 10-day stretch.²

As a largely ambulatory specialty that relies on visual examination, dermatology was no exception to the swing toward telemedicine, or teledermatology (TD). Before the COVID-19 pandemic, 14.1% (82 of 582 respondents) of practicing US dermatologists reported having used teledermatology, compared to 96.9% (572/591) during the pandemic.³ Even at my home institution (Massachusetts General Hospital [Boston, Massachusetts] and its 12 affiliated dermatology clinics), the number of in-person visits in April 2020 (n=67) was less than 1% of that in April 2019 (n=7919), whereas there was a total of 1564 virtual visits in April 2020 compared to zero the year prior. Virtual provider-to-provider consults (e-consultations) also saw an increase of more than 20%, suggesting that dermatology’s avid adoption of TD also had improved the perceived accessibility of our specialty.⁴

The adoption and adaptation of TD are projected to continue to grow rapidly across the globe, as digitalization has enhanced access without increasing costs, shortened wait times, and even created opportunities for primary care providers based in rural or overseas locations to learn the diagnosis and treatment of skin disease.⁵ Residents and fellows should be privy to the nuances of training and practicing in this digital era, as our careers inevitably will involve some facet of TD.

The Art of Medicine

Touch, a sense that perhaps ranks second to sight in dermatology, is absent in TD. In either synchronous (live-interactive, face video visits) or asynchronous (store-and-forward, where digital photographs and clinical information sent by patients or referring physicians are assessed at a later time) TD, the skin cannot be rubbed for texture, pinched for thickness, or pushed for blanching. Instead, all we have is vision. Irwin Braverman, MD, Professor Emeritus of Dermatology at Yale University (New Haven, Connecticut), alongside Jacqueline Dolev, MD, dermatologist and Yale graduate, and Linda Friedlaender, curator at the Yale Center for British Art, founded an observational skills workshop in which trainees learn to observe and describe the paintings housed in the museum, noting all memorable details: the color of the sky, the actions of the animals, and the facial expressions of the people. A study of 90 participants over a 2-year period found that following the workshop, the ability to identify key diagnostic details from clinical photography improved by more than 10%.⁶ Other studies also utilizing fine art as a medical training tool to improve “visual literacy” saw similarly increased sophistication in the description of clinical imagery, which translated to better diagnostic acumen.⁷ Confined to video and photographs, TD necessitates trainees and practicing dermatologists to be excellent visual diagnosticians. Although surveyed dermatologists believe TD is presently appropriate for acne, benign lesions, or follow-up appointments,³ conditions for which patients have been examined via TD have included drug eruptions, premalignant or malignant neoplasms, infections, and papulosquamous or inflammatory dermatoses.⁸ At the very least, clinicians should be versed in identifying those conditions that require in-person evaluation, as patients cannot be held responsible to distinguish which situations can and cannot be addressed virtually.

Issues of Patient-Physician Confidentiality

Teledermatology is not without its shortcomings; critics have noted diagnostic challenges with poor quality photographs or videos, inability to perform total-body skin examinations, and socioeconomic limitations due to broadband availability and speed.^5,9 Although most of these shortcomings are outside of our control, a key challenge within the purview of the provider is the protection of patient privacy.

Much of the salient concerns regarding patient-physician confidentiality involve asynchronous TD, where store-and-forward data sharing allows physicians to download patient photographs or information onto their personal email or smartphones.¹⁰ Although some hospital systems provide encryption software or hospital-sponsored devices to ensure security, physicians may opt to use their personal phones or laptops out of convenience or to save time.^10,11 One study found that less than 30% of smartphone users choose to activate user authentication on their devices, even ones as simple as a passphrase.¹¹ The digital exchange of information thus poses an immense risk for compromising protected health information (PHI), as personal devices can be easily lost, stolen, or hacked. Indeed, in 2015, more than 113 million individuals were affected by a breach of PHI, the majority over hacked network servers.¹² With the growing diversity of mediums through which PHI is exchanged, such as videoconferencing and instant messaging, the potential medicolegal risks of information breach continue to climb. The US Department of Health & Human Services urges health care providers to uphold best practices for security, including encrypting data, updating all software including antivirus software, using multifactor authentication, and following local cybersecurity regulations or recommendations.¹³ For synchronous TD, suggested best practices include utilizing headphones during live appointments, avoiding public wireless networks, and ensuring the provider and patient both scan the room with their device’s camera before the start of the visit.¹⁴

On the Horizon of Teledermatology

What can we expect in the coming years? Increased utilization of telemedicine will translate into data that will help address questions surrounding safety, diagnostic accuracy, privacy, and accessibility. One aspect of TD in need of clarity is a guideline on payment and reimbursement, and whether TD can continue to be financially attractive to providers. Starting in 2020, the Centers for Medicare & Medicaid Services removed geographic restrictions for reimbursement of telemedicine visits, enabling even urban-residing patients to enjoy the convenience of TD. This followed a prior relaxation of restrictions, where even prerecorded patient information became eligible for Medicare reimbursement.⁹ However, as virtual visits tend to be shorter with fewer diagnostic services compared to in-person visits, the reimbursement structure of TD must be nuanced, which is the subject of ongoing study and modification in the wake of the COVID-19 pandemic.¹⁵

Another point to consider is the explosion of direct-to-consumer TD, which allows patients to receive virtual dermatologic care or prescription medication without a pre-established relationship with any physician. In 2017, there were 22 direct-to-consumer TD services available to US patients in 45 states, 16 (73%) of which provided dermatologic care for any concern while 6 (27%) were limited to acne or antiaging and were largely prescription oriented. Orchestrated mostly by the for-profit private sector, direct-to-consumer companies are poorly regulated and have raised concerns over questionable practices, such as the use of non–US board-certified physicians, exorbitant fees, and failure to disclose medication side effects.¹⁶ A study of 16 direct-to-consumer telemedicine sites found substantial discordance in the suggested management of the same patient, and many of the services relied heavily on patient-provided self-diagnoses, such as a case where psoriasis medication was dispensed for a psoriasis patient who submitted a photograph of his syphilitic rash.¹⁷ Despite these problems, consumers show a willingness to pay out of pocket to access these services for their shorter waiting times and convenience.¹⁸ Hence, we must learn to ask about direct-to-consumer service use when obtaining a thorough history and be open to counseling our patients on the proper use and potential risks of direct-to-consumer TD.

Final Thoughts

The telemedicine industry is expected to reach more than $130 billion by 2025, with more than 90% of surveyed health care executives planning for the adoption and incorporation of telemedicine into their business models.¹⁹ The COVID-19 pandemic was an impetus for an exponential adoption of TD, and it would behoove current residents to realize that the practice of dermatology will continue to be increasingly digitalized within the coming years. Whether through formal training or self-assessment, we must strive to grow as proficient virtual dermatologists while upholding professionalism, patient safety, and health information privacy.

The COVID-19 pandemic largely altered the practice of medicine, including a rapid expansion of telemedicine following the March 2020 World Health Organization guidelines for social distancing, which recommended suspension of all nonurgent in-person visits.¹ Expectedly, COVID-related urgent care visits initially comprised the bulk of the new telemedicine wave: NYU Langone Health (New York, New York), for example, saw a 683% increase in virtual visits between March and April 2020, most (55.3%) of which were for respiratory concerns. In-person visits, on the other hand, concurrently fell by more than 80%. Interestingly, nonurgent ambulatory care specialties also saw a considerable uptick in virtual encounters, from less than 50 visits in a typical day to an average of 7000 in a 10-day stretch.²

As a largely ambulatory specialty that relies on visual examination, dermatology was no exception to the swing toward telemedicine, or teledermatology (TD). Before the COVID-19 pandemic, 14.1% (82 of 582 respondents) of practicing US dermatologists reported having used teledermatology, compared to 96.9% (572/591) during the pandemic.³ Even at my home institution (Massachusetts General Hospital [Boston, Massachusetts] and its 12 affiliated dermatology clinics), the number of in-person visits in April 2020 (n=67) was less than 1% of that in April 2019 (n=7919), whereas there was a total of 1564 virtual visits in April 2020 compared to zero the year prior. Virtual provider-to-provider consults (e-consultations) also saw an increase of more than 20%, suggesting that dermatology’s avid adoption of TD also had improved the perceived accessibility of our specialty.⁴

The adoption and adaptation of TD are projected to continue to grow rapidly across the globe, as digitalization has enhanced access without increasing costs, shortened wait times, and even created opportunities for primary care providers based in rural or overseas locations to learn the diagnosis and treatment of skin disease.⁵ Residents and fellows should be privy to the nuances of training and practicing in this digital era, as our careers inevitably will involve some facet of TD.

The Art of Medicine

Touch, a sense that perhaps ranks second to sight in dermatology, is absent in TD. In either synchronous (live-interactive, face video visits) or asynchronous (store-and-forward, where digital photographs and clinical information sent by patients or referring physicians are assessed at a later time) TD, the skin cannot be rubbed for texture, pinched for thickness, or pushed for blanching. Instead, all we have is vision. Irwin Braverman, MD, Professor Emeritus of Dermatology at Yale University (New Haven, Connecticut), alongside Jacqueline Dolev, MD, dermatologist and Yale graduate, and Linda Friedlaender, curator at the Yale Center for British Art, founded an observational skills workshop in which trainees learn to observe and describe the paintings housed in the museum, noting all memorable details: the color of the sky, the actions of the animals, and the facial expressions of the people. A study of 90 participants over a 2-year period found that following the workshop, the ability to identify key diagnostic details from clinical photography improved by more than 10%.⁶ Other studies also utilizing fine art as a medical training tool to improve “visual literacy” saw similarly increased sophistication in the description of clinical imagery, which translated to better diagnostic acumen.⁷ Confined to video and photographs, TD necessitates trainees and practicing dermatologists to be excellent visual diagnosticians. Although surveyed dermatologists believe TD is presently appropriate for acne, benign lesions, or follow-up appointments,³ conditions for which patients have been examined via TD have included drug eruptions, premalignant or malignant neoplasms, infections, and papulosquamous or inflammatory dermatoses.⁸ At the very least, clinicians should be versed in identifying those conditions that require in-person evaluation, as patients cannot be held responsible to distinguish which situations can and cannot be addressed virtually.

Issues of Patient-Physician Confidentiality

Teledermatology is not without its shortcomings; critics have noted diagnostic challenges with poor quality photographs or videos, inability to perform total-body skin examinations, and socioeconomic limitations due to broadband availability and speed.^5,9 Although most of these shortcomings are outside of our control, a key challenge within the purview of the provider is the protection of patient privacy.

Much of the salient concerns regarding patient-physician confidentiality involve asynchronous TD, where store-and-forward data sharing allows physicians to download patient photographs or information onto their personal email or smartphones.¹⁰ Although some hospital systems provide encryption software or hospital-sponsored devices to ensure security, physicians may opt to use their personal phones or laptops out of convenience or to save time.^10,11 One study found that less than 30% of smartphone users choose to activate user authentication on their devices, even ones as simple as a passphrase.¹¹ The digital exchange of information thus poses an immense risk for compromising protected health information (PHI), as personal devices can be easily lost, stolen, or hacked. Indeed, in 2015, more than 113 million individuals were affected by a breach of PHI, the majority over hacked network servers.¹² With the growing diversity of mediums through which PHI is exchanged, such as videoconferencing and instant messaging, the potential medicolegal risks of information breach continue to climb. The US Department of Health & Human Services urges health care providers to uphold best practices for security, including encrypting data, updating all software including antivirus software, using multifactor authentication, and following local cybersecurity regulations or recommendations.¹³ For synchronous TD, suggested best practices include utilizing headphones during live appointments, avoiding public wireless networks, and ensuring the provider and patient both scan the room with their device’s camera before the start of the visit.¹⁴

On the Horizon of Teledermatology

What can we expect in the coming years? Increased utilization of telemedicine will translate into data that will help address questions surrounding safety, diagnostic accuracy, privacy, and accessibility. One aspect of TD in need of clarity is a guideline on payment and reimbursement, and whether TD can continue to be financially attractive to providers. Starting in 2020, the Centers for Medicare & Medicaid Services removed geographic restrictions for reimbursement of telemedicine visits, enabling even urban-residing patients to enjoy the convenience of TD. This followed a prior relaxation of restrictions, where even prerecorded patient information became eligible for Medicare reimbursement.⁹ However, as virtual visits tend to be shorter with fewer diagnostic services compared to in-person visits, the reimbursement structure of TD must be nuanced, which is the subject of ongoing study and modification in the wake of the COVID-19 pandemic.¹⁵

Another point to consider is the explosion of direct-to-consumer TD, which allows patients to receive virtual dermatologic care or prescription medication without a pre-established relationship with any physician. In 2017, there were 22 direct-to-consumer TD services available to US patients in 45 states, 16 (73%) of which provided dermatologic care for any concern while 6 (27%) were limited to acne or antiaging and were largely prescription oriented. Orchestrated mostly by the for-profit private sector, direct-to-consumer companies are poorly regulated and have raised concerns over questionable practices, such as the use of non–US board-certified physicians, exorbitant fees, and failure to disclose medication side effects.¹⁶ A study of 16 direct-to-consumer telemedicine sites found substantial discordance in the suggested management of the same patient, and many of the services relied heavily on patient-provided self-diagnoses, such as a case where psoriasis medication was dispensed for a psoriasis patient who submitted a photograph of his syphilitic rash.¹⁷ Despite these problems, consumers show a willingness to pay out of pocket to access these services for their shorter waiting times and convenience.¹⁸ Hence, we must learn to ask about direct-to-consumer service use when obtaining a thorough history and be open to counseling our patients on the proper use and potential risks of direct-to-consumer TD.

Final Thoughts

The telemedicine industry is expected to reach more than $130 billion by 2025, with more than 90% of surveyed health care executives planning for the adoption and incorporation of telemedicine into their business models.¹⁹ The COVID-19 pandemic was an impetus for an exponential adoption of TD, and it would behoove current residents to realize that the practice of dermatology will continue to be increasingly digitalized within the coming years. Whether through formal training or self-assessment, we must strive to grow as proficient virtual dermatologists while upholding professionalism, patient safety, and health information privacy.

To the Editor:

With a steady increase in dermatology publications over recent decades, there is an expanding pool of evidence to address clinical questions.¹ Residency training is the time when appraising the medical literature and practicing evidence-based medicine is most honed. Evidence-based medicine is an essential component of Practice-based Learning and Improvement, a required core competency of the Accreditation Council for Graduate Medical Education.² Assimilation of new research evidence is traditionally taught through didactics and journal club discussions in residency.

However, at a time when the demand for information overwhelms safeguards that exist to evaluate its quality, it is more important than ever to be equipped with the proper tools to critically appraise novel literature. Beyond accepting a scientific article at face value, physicians must learn to ask targeted questions of the study design, results, and clinical relevance. These questions change based on the type of study, and organizations such as the Oxford Centre for Evidence-Based Medicine provide guidance through critical appraisal worksheets.³

To investigate the utility of using guided questions to evaluate the reliability, significance, and applicability of clinical evidence, we beta tested a novel web-based application in an academic dermatology setting to design and run a journal club for residents. Six dermatology residents participated in this institutional review board–approved study comprised of 3 phases: (1) independent article appraisal through the web-based application, (2) group discussion, and (3) anonymous postsurvey.

Using this platform, we uploaded a recent article into the interactive reader, which contained an integrated tool for appraisal based on specific questions. Because the article described the results of a randomized clinical trial, we used questions from the Centre for Evidence-Based Medicine’s Randomised Controlled Trials Critical Appraisal Worksheet, which has a series of questions to evaluate internal validity, results, and external validity and applicability.³

Residents used the platform to independently read the article, highlight areas of the text that corresponded to 8 critical appraisal questions, and answer yes or no to these questions. Based on residents’ answers, a final appraisal score (on a scale of 1% to 100%) was generated. Simultaneously, the attending dermatologist leading the journal club (C.W.) also completed the assignment to establish an expert score.

Scores from the residents’ independent appraisal ranged from 75% to 100% (mean, 85.4%). Upon discussing the article in a group setting, the residents established a consensus score of 75%. This consensus score matched the expert score, which suggested to us that both independently reviewing the article using guided questions and conducting a group debriefing were necessary to match the expert level of critical appraisal.

Of note, the residents’ average independent appraisal score was higher than both the consensus and expert scores, indicating that the residents evaluated the article less critically on their own. With more practice using this method, it is possible that the precision and accuracy of the residents’ critical appraisal of scientific articles will improve.

In the postsurvey, we asked residents about the critical appraisal of the medical literature. All residents agreed that evaluating the quality of evidence when reading a scientific article was somewhat important or very important to them; however, only 2 of 6 evaluated the quality of evidence all the time, and the other 4 did so half of the time or less than half of the time.

When critically appraising articles, 2 of 6 residents used specific rubrics half of the time; 4 of 6 less than half of the time. Most important, 5 of 6 residents agreed that the quality of evidence affected their management decisions more than half of the time or all of the time. Although it is clear that residents value evidence-based medicine and understand the importance of evaluating the quality of evidence, doing so currently might not be simple or practical.

An organized framework for appraising articles would streamline the process. Five of 6 residents agreed that the use of specific questions as a guide made it easier to appraise an article for the quality of its evidence. Four of 6 residents found that juxtaposing specific questions with the interactive reader was helpful; 5 of 6 agreed that they would use a web-based journal club platform if given the option.

Lastly, 5 of 6 residents agreed that if such a tool were available, a platform containing all major dermatology publications in an interactive reader format, along with relevant appraisal questions on the side, would be useful.

This pilot study augmented the typical journal club experience by emphasizing goal-directed reading and the importance of analyzing the quality of evidence. The combination of independent appraisal of an article using targeted questions and a group debrief led to better understanding of the evidence and its clinical applicability. The COVID-19 pandemic may be a better time than ever to explore innovative ways to teach evidence-based medicine in residency training.

To the Editor:

With a steady increase in dermatology publications over recent decades, there is an expanding pool of evidence to address clinical questions.¹ Residency training is the time when appraising the medical literature and practicing evidence-based medicine is most honed. Evidence-based medicine is an essential component of Practice-based Learning and Improvement, a required core competency of the Accreditation Council for Graduate Medical Education.² Assimilation of new research evidence is traditionally taught through didactics and journal club discussions in residency.

However, at a time when the demand for information overwhelms safeguards that exist to evaluate its quality, it is more important than ever to be equipped with the proper tools to critically appraise novel literature. Beyond accepting a scientific article at face value, physicians must learn to ask targeted questions of the study design, results, and clinical relevance. These questions change based on the type of study, and organizations such as the Oxford Centre for Evidence-Based Medicine provide guidance through critical appraisal worksheets.³

To investigate the utility of using guided questions to evaluate the reliability, significance, and applicability of clinical evidence, we beta tested a novel web-based application in an academic dermatology setting to design and run a journal club for residents. Six dermatology residents participated in this institutional review board–approved study comprised of 3 phases: (1) independent article appraisal through the web-based application, (2) group discussion, and (3) anonymous postsurvey.

Using this platform, we uploaded a recent article into the interactive reader, which contained an integrated tool for appraisal based on specific questions. Because the article described the results of a randomized clinical trial, we used questions from the Centre for Evidence-Based Medicine’s Randomised Controlled Trials Critical Appraisal Worksheet, which has a series of questions to evaluate internal validity, results, and external validity and applicability.³

Residents used the platform to independently read the article, highlight areas of the text that corresponded to 8 critical appraisal questions, and answer yes or no to these questions. Based on residents’ answers, a final appraisal score (on a scale of 1% to 100%) was generated. Simultaneously, the attending dermatologist leading the journal club (C.W.) also completed the assignment to establish an expert score.

Scores from the residents’ independent appraisal ranged from 75% to 100% (mean, 85.4%). Upon discussing the article in a group setting, the residents established a consensus score of 75%. This consensus score matched the expert score, which suggested to us that both independently reviewing the article using guided questions and conducting a group debriefing were necessary to match the expert level of critical appraisal.

Of note, the residents’ average independent appraisal score was higher than both the consensus and expert scores, indicating that the residents evaluated the article less critically on their own. With more practice using this method, it is possible that the precision and accuracy of the residents’ critical appraisal of scientific articles will improve.

In the postsurvey, we asked residents about the critical appraisal of the medical literature. All residents agreed that evaluating the quality of evidence when reading a scientific article was somewhat important or very important to them; however, only 2 of 6 evaluated the quality of evidence all the time, and the other 4 did so half of the time or less than half of the time.

When critically appraising articles, 2 of 6 residents used specific rubrics half of the time; 4 of 6 less than half of the time. Most important, 5 of 6 residents agreed that the quality of evidence affected their management decisions more than half of the time or all of the time. Although it is clear that residents value evidence-based medicine and understand the importance of evaluating the quality of evidence, doing so currently might not be simple or practical.

An organized framework for appraising articles would streamline the process. Five of 6 residents agreed that the use of specific questions as a guide made it easier to appraise an article for the quality of its evidence. Four of 6 residents found that juxtaposing specific questions with the interactive reader was helpful; 5 of 6 agreed that they would use a web-based journal club platform if given the option.

Lastly, 5 of 6 residents agreed that if such a tool were available, a platform containing all major dermatology publications in an interactive reader format, along with relevant appraisal questions on the side, would be useful.

This pilot study augmented the typical journal club experience by emphasizing goal-directed reading and the importance of analyzing the quality of evidence. The combination of independent appraisal of an article using targeted questions and a group debrief led to better understanding of the evidence and its clinical applicability. The COVID-19 pandemic may be a better time than ever to explore innovative ways to teach evidence-based medicine in residency training.

To the Editor:

With a steady increase in dermatology publications over recent decades, there is an expanding pool of evidence to address clinical questions.¹ Residency training is the time when appraising the medical literature and practicing evidence-based medicine is most honed. Evidence-based medicine is an essential component of Practice-based Learning and Improvement, a required core competency of the Accreditation Council for Graduate Medical Education.² Assimilation of new research evidence is traditionally taught through didactics and journal club discussions in residency.

However, at a time when the demand for information overwhelms safeguards that exist to evaluate its quality, it is more important than ever to be equipped with the proper tools to critically appraise novel literature. Beyond accepting a scientific article at face value, physicians must learn to ask targeted questions of the study design, results, and clinical relevance. These questions change based on the type of study, and organizations such as the Oxford Centre for Evidence-Based Medicine provide guidance through critical appraisal worksheets.³

To investigate the utility of using guided questions to evaluate the reliability, significance, and applicability of clinical evidence, we beta tested a novel web-based application in an academic dermatology setting to design and run a journal club for residents. Six dermatology residents participated in this institutional review board–approved study comprised of 3 phases: (1) independent article appraisal through the web-based application, (2) group discussion, and (3) anonymous postsurvey.

Using this platform, we uploaded a recent article into the interactive reader, which contained an integrated tool for appraisal based on specific questions. Because the article described the results of a randomized clinical trial, we used questions from the Centre for Evidence-Based Medicine’s Randomised Controlled Trials Critical Appraisal Worksheet, which has a series of questions to evaluate internal validity, results, and external validity and applicability.³

Residents used the platform to independently read the article, highlight areas of the text that corresponded to 8 critical appraisal questions, and answer yes or no to these questions. Based on residents’ answers, a final appraisal score (on a scale of 1% to 100%) was generated. Simultaneously, the attending dermatologist leading the journal club (C.W.) also completed the assignment to establish an expert score.

Scores from the residents’ independent appraisal ranged from 75% to 100% (mean, 85.4%). Upon discussing the article in a group setting, the residents established a consensus score of 75%. This consensus score matched the expert score, which suggested to us that both independently reviewing the article using guided questions and conducting a group debriefing were necessary to match the expert level of critical appraisal.

Of note, the residents’ average independent appraisal score was higher than both the consensus and expert scores, indicating that the residents evaluated the article less critically on their own. With more practice using this method, it is possible that the precision and accuracy of the residents’ critical appraisal of scientific articles will improve.

In the postsurvey, we asked residents about the critical appraisal of the medical literature. All residents agreed that evaluating the quality of evidence when reading a scientific article was somewhat important or very important to them; however, only 2 of 6 evaluated the quality of evidence all the time, and the other 4 did so half of the time or less than half of the time.

When critically appraising articles, 2 of 6 residents used specific rubrics half of the time; 4 of 6 less than half of the time. Most important, 5 of 6 residents agreed that the quality of evidence affected their management decisions more than half of the time or all of the time. Although it is clear that residents value evidence-based medicine and understand the importance of evaluating the quality of evidence, doing so currently might not be simple or practical.

An organized framework for appraising articles would streamline the process. Five of 6 residents agreed that the use of specific questions as a guide made it easier to appraise an article for the quality of its evidence. Four of 6 residents found that juxtaposing specific questions with the interactive reader was helpful; 5 of 6 agreed that they would use a web-based journal club platform if given the option.

Lastly, 5 of 6 residents agreed that if such a tool were available, a platform containing all major dermatology publications in an interactive reader format, along with relevant appraisal questions on the side, would be useful.

This pilot study augmented the typical journal club experience by emphasizing goal-directed reading and the importance of analyzing the quality of evidence. The combination of independent appraisal of an article using targeted questions and a group debrief led to better understanding of the evidence and its clinical applicability. The COVID-19 pandemic may be a better time than ever to explore innovative ways to teach evidence-based medicine in residency training.

First-year psychiatry resident Jake Goodman, MD, knew he was taking a chance when he opened up on his popular social media platforms about his personal mental health battle. He mulled over the decision for several weeks before deciding to take the plunge.

As he voiced recently on his TikTok page, his biggest social media fanbase, with 1.3 million followers, it felt freeing to get his personal struggle off his chest.

“I’m a doctor in training, and most doctors would advise me not to post this,” the 29-year-old from Miami said in the video last month, which garnered 1.2 million views on TikTok alone. “They would say it’s risky for my career. But I didn’t join the medical field to continue the toxic status quo. I’m part of a new generation of health care professionals that are not afraid to be vulnerable and talk about mental health.”

“Dr. Jake,” as he calls himself on social media, admitted he was a physician who treats mental illness and also takes medication for it. “It felt good to say that. And by the way, I’m proud of it,” he said in the TikTok post.

A champion of mental health throughout the pandemic, Dr. Goodman called attention to the illness in the medical field. In a message on Instagram, he stated, “Opening up about your mental health as a medical professional, especially as a doctor who treats mental illness, can be taboo ... So here’s me leading by example.”

He also cited statistics on the challenge: “1 in 2 people will be diagnosed with a mental health illness at some point in their life. Yet many of us will never take medication that can help correct the chemical imbalance in our brains due to medication stigma: the fear that taking medications for our mental health somehow makes us weak.”

Mental health remains an issue among residents. Nearly 70% of residents polled by Medscape in its 2021 Residents Lifestyle & Happiness Report said they strongly or somewhat agree there’s a stigma against seeking mental health help. And nearly half, or 47% of those polled, said they sometimes (36%) or always/most of the time (11%) were depressed. The latter category rose in the past year.

Dr. Goodman told this news organization that he became passionate about mental health when he lost a college friend to suicide. “It really exposed the stigma” of mental health, he said. “I always knew it was there, but it took me seeing someone lose his life and [asking] why didn’t he feel comfortable talking to us, and why didn’t I feel comfortable talking to him?”
 

Stress of medical training

The decision to pursue psychiatry as his specialty came after a rotation in a clinic for people struggling with substance use disorders. “I was enthralled to see people change their life ... just by mental health care.” It’s why he went into medicine, he tells this news organization. “I always wanted to be in a field to help people [before they hit] rock bottom, when no one else could be there for them.”

Dr. Goodman’s personal battle with mental health didn’t arise until he started residency. “I was not really myself.” He said he felt numb and burned out. “I was not getting as much enjoyment out of things.” A friend pointed out that he might be depressed, so he went to see a therapist and then a psychiatrist and started on medication. “It had a profound impact on how I felt.”

Still, it took a while before Dr. Goodman was comfortable sharing his story with the 1.6 million followers he had already built across his social media platforms.

“I started on social media in 2020 with the goal of advocating for mental health and inspiring future doctors.” He said the message seemed to resonate with people struggling during the early part of the pandemic. On his social media accounts, he also talks about medical school, residency, and being a health care provider. His fiancé is also a resident doctor, in internal medicine.

Dr. Goodman is also trying to create a more realistic image of doctors than the superheroes he believed they were growing up. He wants those who grow up wanting to be doctors and who look up to him to see him as a human being with vulnerabilities, such as mental health.

“You can be a doctor and have mental health issues. Seeking treatment for mental health makes you a better doctor, and for other health care workers suffering in the midst of the pandemic, I want to let them know they are not alone.”

He pointed to the statistic that doctors have one of the highest suicide rates of any professions. “It’s better to talk about that in the early stages of training.”

Students, residents, or attending physicians who have mental health challenges shouldn’t allow their symptoms to go untreated, Dr. Goodman added. “Holding in all the stress and anxiety and feelings in a very traumatic field may be dangerous. Opening up and seeking treatment, that’s the brave thing to do.”

One of his goals is to campaign for the removal of a question on state medical licensing forms requiring doctors to report any mental health diagnosis. It’s why doctors may be afraid to admit that they are struggling. “I’m still here. It didn’t ruin my career.”

Doctors who seek treatment for mental health are theoretically protected under the Americans With Disabilities Act from being refused a license on the basis of that diagnosis. Dr. Goodman hopes to advocate at the state level to reduce discrimination and increase accessibility for doctors to seek mental health care.

Still, Dr. Goodman concedes he was initially fearful of the repercussions. “I opened up about it because this post could save lives. I was doing what I believed in.”

So if he runs into barriers to receive his medical license because of his admission, “that’s a serious problem,” he said. “There is already a shortage of doctors. We’ll see what happens in a few years. I am not the only one who will answer ‘yes’ to having sought treatment for a mental illness. The questions do not really need to be there.”

A version of this article first appeared on Medscape.com.

First-year psychiatry resident Jake Goodman, MD, knew he was taking a chance when he opened up on his popular social media platforms about his personal mental health battle. He mulled over the decision for several weeks before deciding to take the plunge.

As he voiced recently on his TikTok page, his biggest social media fanbase, with 1.3 million followers, it felt freeing to get his personal struggle off his chest.

“I’m a doctor in training, and most doctors would advise me not to post this,” the 29-year-old from Miami said in the video last month, which garnered 1.2 million views on TikTok alone. “They would say it’s risky for my career. But I didn’t join the medical field to continue the toxic status quo. I’m part of a new generation of health care professionals that are not afraid to be vulnerable and talk about mental health.”

“Dr. Jake,” as he calls himself on social media, admitted he was a physician who treats mental illness and also takes medication for it. “It felt good to say that. And by the way, I’m proud of it,” he said in the TikTok post.

A champion of mental health throughout the pandemic, Dr. Goodman called attention to the illness in the medical field. In a message on Instagram, he stated, “Opening up about your mental health as a medical professional, especially as a doctor who treats mental illness, can be taboo ... So here’s me leading by example.”

He also cited statistics on the challenge: “1 in 2 people will be diagnosed with a mental health illness at some point in their life. Yet many of us will never take medication that can help correct the chemical imbalance in our brains due to medication stigma: the fear that taking medications for our mental health somehow makes us weak.”

Mental health remains an issue among residents. Nearly 70% of residents polled by Medscape in its 2021 Residents Lifestyle & Happiness Report said they strongly or somewhat agree there’s a stigma against seeking mental health help. And nearly half, or 47% of those polled, said they sometimes (36%) or always/most of the time (11%) were depressed. The latter category rose in the past year.

Dr. Goodman told this news organization that he became passionate about mental health when he lost a college friend to suicide. “It really exposed the stigma” of mental health, he said. “I always knew it was there, but it took me seeing someone lose his life and [asking] why didn’t he feel comfortable talking to us, and why didn’t I feel comfortable talking to him?”
 

Stress of medical training

The decision to pursue psychiatry as his specialty came after a rotation in a clinic for people struggling with substance use disorders. “I was enthralled to see people change their life ... just by mental health care.” It’s why he went into medicine, he tells this news organization. “I always wanted to be in a field to help people [before they hit] rock bottom, when no one else could be there for them.”

Dr. Goodman’s personal battle with mental health didn’t arise until he started residency. “I was not really myself.” He said he felt numb and burned out. “I was not getting as much enjoyment out of things.” A friend pointed out that he might be depressed, so he went to see a therapist and then a psychiatrist and started on medication. “It had a profound impact on how I felt.”

Still, it took a while before Dr. Goodman was comfortable sharing his story with the 1.6 million followers he had already built across his social media platforms.

“I started on social media in 2020 with the goal of advocating for mental health and inspiring future doctors.” He said the message seemed to resonate with people struggling during the early part of the pandemic. On his social media accounts, he also talks about medical school, residency, and being a health care provider. His fiancé is also a resident doctor, in internal medicine.

Dr. Goodman is also trying to create a more realistic image of doctors than the superheroes he believed they were growing up. He wants those who grow up wanting to be doctors and who look up to him to see him as a human being with vulnerabilities, such as mental health.

“You can be a doctor and have mental health issues. Seeking treatment for mental health makes you a better doctor, and for other health care workers suffering in the midst of the pandemic, I want to let them know they are not alone.”

He pointed to the statistic that doctors have one of the highest suicide rates of any professions. “It’s better to talk about that in the early stages of training.”

Students, residents, or attending physicians who have mental health challenges shouldn’t allow their symptoms to go untreated, Dr. Goodman added. “Holding in all the stress and anxiety and feelings in a very traumatic field may be dangerous. Opening up and seeking treatment, that’s the brave thing to do.”

One of his goals is to campaign for the removal of a question on state medical licensing forms requiring doctors to report any mental health diagnosis. It’s why doctors may be afraid to admit that they are struggling. “I’m still here. It didn’t ruin my career.”

Doctors who seek treatment for mental health are theoretically protected under the Americans With Disabilities Act from being refused a license on the basis of that diagnosis. Dr. Goodman hopes to advocate at the state level to reduce discrimination and increase accessibility for doctors to seek mental health care.

Still, Dr. Goodman concedes he was initially fearful of the repercussions. “I opened up about it because this post could save lives. I was doing what I believed in.”

So if he runs into barriers to receive his medical license because of his admission, “that’s a serious problem,” he said. “There is already a shortage of doctors. We’ll see what happens in a few years. I am not the only one who will answer ‘yes’ to having sought treatment for a mental illness. The questions do not really need to be there.”

A version of this article first appeared on Medscape.com.

First-year psychiatry resident Jake Goodman, MD, knew he was taking a chance when he opened up on his popular social media platforms about his personal mental health battle. He mulled over the decision for several weeks before deciding to take the plunge.

As he voiced recently on his TikTok page, his biggest social media fanbase, with 1.3 million followers, it felt freeing to get his personal struggle off his chest.

“I’m a doctor in training, and most doctors would advise me not to post this,” the 29-year-old from Miami said in the video last month, which garnered 1.2 million views on TikTok alone. “They would say it’s risky for my career. But I didn’t join the medical field to continue the toxic status quo. I’m part of a new generation of health care professionals that are not afraid to be vulnerable and talk about mental health.”

“Dr. Jake,” as he calls himself on social media, admitted he was a physician who treats mental illness and also takes medication for it. “It felt good to say that. And by the way, I’m proud of it,” he said in the TikTok post.

A champion of mental health throughout the pandemic, Dr. Goodman called attention to the illness in the medical field. In a message on Instagram, he stated, “Opening up about your mental health as a medical professional, especially as a doctor who treats mental illness, can be taboo ... So here’s me leading by example.”

He also cited statistics on the challenge: “1 in 2 people will be diagnosed with a mental health illness at some point in their life. Yet many of us will never take medication that can help correct the chemical imbalance in our brains due to medication stigma: the fear that taking medications for our mental health somehow makes us weak.”

Mental health remains an issue among residents. Nearly 70% of residents polled by Medscape in its 2021 Residents Lifestyle & Happiness Report said they strongly or somewhat agree there’s a stigma against seeking mental health help. And nearly half, or 47% of those polled, said they sometimes (36%) or always/most of the time (11%) were depressed. The latter category rose in the past year.

Dr. Goodman told this news organization that he became passionate about mental health when he lost a college friend to suicide. “It really exposed the stigma” of mental health, he said. “I always knew it was there, but it took me seeing someone lose his life and [asking] why didn’t he feel comfortable talking to us, and why didn’t I feel comfortable talking to him?”
 

Stress of medical training

The decision to pursue psychiatry as his specialty came after a rotation in a clinic for people struggling with substance use disorders. “I was enthralled to see people change their life ... just by mental health care.” It’s why he went into medicine, he tells this news organization. “I always wanted to be in a field to help people [before they hit] rock bottom, when no one else could be there for them.”

Dr. Goodman’s personal battle with mental health didn’t arise until he started residency. “I was not really myself.” He said he felt numb and burned out. “I was not getting as much enjoyment out of things.” A friend pointed out that he might be depressed, so he went to see a therapist and then a psychiatrist and started on medication. “It had a profound impact on how I felt.”

Still, it took a while before Dr. Goodman was comfortable sharing his story with the 1.6 million followers he had already built across his social media platforms.

“I started on social media in 2020 with the goal of advocating for mental health and inspiring future doctors.” He said the message seemed to resonate with people struggling during the early part of the pandemic. On his social media accounts, he also talks about medical school, residency, and being a health care provider. His fiancé is also a resident doctor, in internal medicine.

Dr. Goodman is also trying to create a more realistic image of doctors than the superheroes he believed they were growing up. He wants those who grow up wanting to be doctors and who look up to him to see him as a human being with vulnerabilities, such as mental health.

“You can be a doctor and have mental health issues. Seeking treatment for mental health makes you a better doctor, and for other health care workers suffering in the midst of the pandemic, I want to let them know they are not alone.”

He pointed to the statistic that doctors have one of the highest suicide rates of any professions. “It’s better to talk about that in the early stages of training.”

Students, residents, or attending physicians who have mental health challenges shouldn’t allow their symptoms to go untreated, Dr. Goodman added. “Holding in all the stress and anxiety and feelings in a very traumatic field may be dangerous. Opening up and seeking treatment, that’s the brave thing to do.”

One of his goals is to campaign for the removal of a question on state medical licensing forms requiring doctors to report any mental health diagnosis. It’s why doctors may be afraid to admit that they are struggling. “I’m still here. It didn’t ruin my career.”

Doctors who seek treatment for mental health are theoretically protected under the Americans With Disabilities Act from being refused a license on the basis of that diagnosis. Dr. Goodman hopes to advocate at the state level to reduce discrimination and increase accessibility for doctors to seek mental health care.

Still, Dr. Goodman concedes he was initially fearful of the repercussions. “I opened up about it because this post could save lives. I was doing what I believed in.”

So if he runs into barriers to receive his medical license because of his admission, “that’s a serious problem,” he said. “There is already a shortage of doctors. We’ll see what happens in a few years. I am not the only one who will answer ‘yes’ to having sought treatment for a mental illness. The questions do not really need to be there.”

A version of this article first appeared on Medscape.com.

The White Coat Ceremony is an enduring memory from my medical school years. Amidst the tumult of memories of seemingly endless sleepless nights spent in libraries and cramming for clerkship examinations between surgical cases, I recall a sunny spring day in 2016 where I gathered with my classmates, family, and friends in the medical school campus courtyard. There were several short, mostly forgotten speeches after which proud fathers and mothers, partners, or siblings slipped the all-important white coat onto the shoulders of the physicians-to-be. At that moment, I felt the weight of tradition centuries in the making resting on my shoulders. Of course, the pomp of the ceremony might have felt a tad overblown had I known that the whole thing had fewer years under its belt than the movie Die Hard.

That’s right, the first White Coat Ceremony was held 5 years after the release of that Bruce Willis classic. Dr. Arnold Gold, a pediatric neurologist on faculty at Columbia University, conceived the ceremony in 1993, and it spread rapidly to medical schools—and later nursing schools—across the United States.¹ Although the values highlighted by the White Coat Ceremony—humanism and compassion in medicine—are timeless, the ceremony itself is a more modern undertaking. What, then, of the white coat itself? Is it the timeless symbol of doctoring—of medicine—that we all presume it to be? Or is it a symbol of modern marketing, just a trend that caught on? And is it encountering its twilight—as trends often do—in the face of changing fashion and, more fundamentally, in changes to who our physicians are and to their roles in our society?

The Cleanliness of the White Coat

Until the end of the 19th century, physicians in the Western world most frequently dressed in black formal wear. The rationale behind this attire seems to have been twofold. First, society as a whole perceived the physician’s work as a serious and formal matter, and any medical encounter had to reflect the gravity of the occasion. Additionally, physicians’ visits often were a portent of impending demise, as physicians in the era prior to antibiotics and antisepsis frequently had little to offer their patients outside of—at best—anecdotal treatments and—at worst—sheer quackery.² Black may have seemed a respectful choice for patients who likely faced dire outcomes regardless of the treatment afforded.³

With the turn of the century came a new understanding of the concepts of antisepsis and disease transmission. While Joseph Lister first published on the use of antisepsis in 1867, his practices did not become commonplace until the early 1900s.⁴ Around the same time came the Flexner report,⁵ the publication of William Osler’s Principles and Practice of Medicine,⁶ and the establishment of the modern medical residency, all of which contributed to the shift from the patient’s own bedside and to the hospital as the house of medicine, with cleanliness and antisepsis as part of its core principles.⁷ The white coat arose as a symbol of purity and freedom from disease. Throughout the 20th century and into the 21st, it has remained the predominant symbol of cleanliness and professionalism for the medical practitioner.

Patient Preference of Physician Attire

Although the white coat may serve as a professional symbol and is well respected medicine, it also plays an important role in the layperson’s perception of their health care providers.⁸ There is little denying that patients prefer their physicians, almost uniformly, to wear a white coat. A systematic review of physician attire that included 30 studies mainly from North America, Europe, and the United Kingdom found that patient preference for formal attire and white coats is near universal.⁹ Patients routinely rate physicians wearing a white coat as more intelligent and trustworthy and feel more confident in the care they will receive.^10-13 They also freely admit that a physician’s appearance influences their satisfaction with their care.¹⁴ The recent adoption of the fleece, or softshell, jacket has not yet pervaded patients’ perceptions of what is considered appropriate physician attire. A 500-respondent survey found that patients were more likely to rate a model wearing a white coat as more professional and experienced compared to the same model wearing a fleece or softshell jacket or other formal attire sans white coat.¹⁵

Closer examination of the same data, however, reveals results reproduced with startling consistency across several studies, which suggest those of us adopting other attire need not dig those white coats out of the closet just yet. First, while many studies point to patient preference for white coats, this preference is uniformly strongest in older patients, beginning around age 40 years and becoming an entrenched preference in those older than 65 years.^9,14,16-18 On the other hand, younger patient populations display little to no such preference, and some studies indicate that younger patients actually prefer scrubs over formal attire in specific settings such as surgical offices, procedural spaces, or the emergency department.^12,14,19 This suggests that bias in favor of traditional physician garb may be more linked to age demographics and may continue to shift as the overall population ages. Additionally, although patients might profess a strong preference for physician attire in theory, it often does not translate into any impact on the patient’s perception of the physician following a clinic visit. The large systematic review on the topic noted that only 25% of studies that surveyed patients about a clinical visit following the encounter reported that physician attire influenced their satisfaction with that visit, suggesting that attire may be less likely to influence patients in the real-world context of receiving care.⁹ In fact, a prospective study of patient perception of medical staff and interactions found that staff style of dress not only had no bearing on the perception of staff or visit satisfaction but that patients often failed to even accurately recall physician attire when surveyed.²⁰ Another survey study echoed these conclusions, finding that physician attire had no effect on the perception of a proposed treatment plan.²¹

What do we know about patient perception of physician attire in the dermatology setting specifically, where visits can be unique in their tendency to transition from medical to procedural in the span of a 15-minute encounter depending on the patient’s chief concern? A survey study of dermatology patients at the general, surgical, and wound care dermatology clinics of an academic medical center (Miami, Florida) found that professional attire with a white coat was strongly preferred across a litany of scenarios assessing many aspects of dermatologic care.²¹ Similarly, a study of patients visiting a single institution’s dermatology and pediatric dermatology clinics surveyed patients and parents regarding attire prior to an appointment and specifically asked if a white coat should be worn.¹³ Fifty-four percent of the adult patients (n=176) surveyed professed a preference for physicians in white coats, with a stronger preference for white coats reported by those 50 years and older (55%; n=113). Parents or guardians presenting to the pediatric dermatology clinic, on the other hand, favored less formal attire.¹³ A recent, real-world study performed at an outpatient dermatology clinic examined the influence of changing physician attire on a patient’s perceptions of care received during clinic encounters. They found no substantial difference in patient satisfaction scores before and following the adoption of a new clinic uniform that transitioned from formal attire to fitted scrubs.²²

With any study of preference, there is the underlying concern over respondent bias. Many of the studies discussed here have found secondarily that a patient’s implicit bias does not end at the clothes their physician is wearing. The survey study of dermatology patients from the academic medical center in Miami, Florida, found that patients preferred that Black physicians of either sex be garbed in professional attire at all times but generally were more accepting of White physicians in less formal attire.²¹ Adamson et al²³ published a response to the study’s findings urging dermatologists to recognize that a physician’s race and gender influence patients’ perceptions in much the same way that physician attire seems to and encouraged the development of a more diverse dermatologic workforce to help combat this prejudice. The issue of bias is not limited to the specialty of dermatology; the recent survey study by Xun et al¹⁵ found that respondents consistently rated female models garbed in physician attire as less professional than male model counterparts. Additionally, female models wearing white coats were mistakenly identified as medical technicians, physician assistants, or nurses with substantially more frequency than males, despite being clothed in the traditional physician garb. Several other publications on the subject have uncovered implicit bias, though it is rarely, if ever, the principle focus of the study.^10,24,25 As is unfortunately true in many professions, female physicians and physicians from ethnic minorities face barriers to being perceived as fully competent physicians.

Impact of the COVID-19 Pandemic

Finally, of course, there is the ever-present question of the effect of the pandemic. Although the exact role of the white coat as a fomite for infection—and especially for the spread of viral illness—remains controversial, the perception nonetheless has helped catalyze the movement to alternatives such as short-sleeved white coats, technical jackets, and more recently, fitted scrubs.^26-29 As with much in this realm, facts seem less important than perceptions; Zahrina et al³⁰ found that when patients were presented with information regarding the risk for microbial contamination associated with white coats, preference for physicians in professional garb plummeted from 72% to only 22%. To date no articles have examined patient perceptions of the white coat in the context of microbial transmission in the age of COVID-19, but future articles on this topic are likely and may serve to further the demise of the white coat.

Final Thoughts

From my vantage point, it seems the white coat will be claimed by the outgoing tide. During this most recent residency interview season, I do not recall a single medical student wearing a short white coat. The closest I came was a quick glimpse of a crumpled white jacket slung over an arm or stuffed in a shoulder bag. Rotating interns and residents from other services on rotation in our department present in softshell or fleece jackets. Fitted scrubs in the newest trendy colors speckle a previously all-white canvas. I, for one, have not donned my own white coat in at least a year, and perhaps it is all for the best. Physician attire is one small aspect of the practice of medicine and likely bears little, if any, relation to the wearer’s qualifications. Our focus should be on building rapport with our patients, providing high-quality care, reducing the risk for nosocomial infection, and developing a health care system that is fair and equitable for patients and health care workers alike, not on who is wearing what. Perhaps the introduction of new physician attire is a small part of the disruption we need to help address persistent gender and racial biases in our field and help shepherd our patients and colleagues to a worldview that is more open and accepting of physicians of diverse backgrounds.

The White Coat Ceremony is an enduring memory from my medical school years. Amidst the tumult of memories of seemingly endless sleepless nights spent in libraries and cramming for clerkship examinations between surgical cases, I recall a sunny spring day in 2016 where I gathered with my classmates, family, and friends in the medical school campus courtyard. There were several short, mostly forgotten speeches after which proud fathers and mothers, partners, or siblings slipped the all-important white coat onto the shoulders of the physicians-to-be. At that moment, I felt the weight of tradition centuries in the making resting on my shoulders. Of course, the pomp of the ceremony might have felt a tad overblown had I known that the whole thing had fewer years under its belt than the movie Die Hard.

That’s right, the first White Coat Ceremony was held 5 years after the release of that Bruce Willis classic. Dr. Arnold Gold, a pediatric neurologist on faculty at Columbia University, conceived the ceremony in 1993, and it spread rapidly to medical schools—and later nursing schools—across the United States.¹ Although the values highlighted by the White Coat Ceremony—humanism and compassion in medicine—are timeless, the ceremony itself is a more modern undertaking. What, then, of the white coat itself? Is it the timeless symbol of doctoring—of medicine—that we all presume it to be? Or is it a symbol of modern marketing, just a trend that caught on? And is it encountering its twilight—as trends often do—in the face of changing fashion and, more fundamentally, in changes to who our physicians are and to their roles in our society?

The Cleanliness of the White Coat

Until the end of the 19th century, physicians in the Western world most frequently dressed in black formal wear. The rationale behind this attire seems to have been twofold. First, society as a whole perceived the physician’s work as a serious and formal matter, and any medical encounter had to reflect the gravity of the occasion. Additionally, physicians’ visits often were a portent of impending demise, as physicians in the era prior to antibiotics and antisepsis frequently had little to offer their patients outside of—at best—anecdotal treatments and—at worst—sheer quackery.² Black may have seemed a respectful choice for patients who likely faced dire outcomes regardless of the treatment afforded.³

With the turn of the century came a new understanding of the concepts of antisepsis and disease transmission. While Joseph Lister first published on the use of antisepsis in 1867, his practices did not become commonplace until the early 1900s.⁴ Around the same time came the Flexner report,⁵ the publication of William Osler’s Principles and Practice of Medicine,⁶ and the establishment of the modern medical residency, all of which contributed to the shift from the patient’s own bedside and to the hospital as the house of medicine, with cleanliness and antisepsis as part of its core principles.⁷ The white coat arose as a symbol of purity and freedom from disease. Throughout the 20th century and into the 21st, it has remained the predominant symbol of cleanliness and professionalism for the medical practitioner.

Patient Preference of Physician Attire

Although the white coat may serve as a professional symbol and is well respected medicine, it also plays an important role in the layperson’s perception of their health care providers.⁸ There is little denying that patients prefer their physicians, almost uniformly, to wear a white coat. A systematic review of physician attire that included 30 studies mainly from North America, Europe, and the United Kingdom found that patient preference for formal attire and white coats is near universal.⁹ Patients routinely rate physicians wearing a white coat as more intelligent and trustworthy and feel more confident in the care they will receive.^10-13 They also freely admit that a physician’s appearance influences their satisfaction with their care.¹⁴ The recent adoption of the fleece, or softshell, jacket has not yet pervaded patients’ perceptions of what is considered appropriate physician attire. A 500-respondent survey found that patients were more likely to rate a model wearing a white coat as more professional and experienced compared to the same model wearing a fleece or softshell jacket or other formal attire sans white coat.¹⁵

Closer examination of the same data, however, reveals results reproduced with startling consistency across several studies, which suggest those of us adopting other attire need not dig those white coats out of the closet just yet. First, while many studies point to patient preference for white coats, this preference is uniformly strongest in older patients, beginning around age 40 years and becoming an entrenched preference in those older than 65 years.^9,14,16-18 On the other hand, younger patient populations display little to no such preference, and some studies indicate that younger patients actually prefer scrubs over formal attire in specific settings such as surgical offices, procedural spaces, or the emergency department.^12,14,19 This suggests that bias in favor of traditional physician garb may be more linked to age demographics and may continue to shift as the overall population ages. Additionally, although patients might profess a strong preference for physician attire in theory, it often does not translate into any impact on the patient’s perception of the physician following a clinic visit. The large systematic review on the topic noted that only 25% of studies that surveyed patients about a clinical visit following the encounter reported that physician attire influenced their satisfaction with that visit, suggesting that attire may be less likely to influence patients in the real-world context of receiving care.⁹ In fact, a prospective study of patient perception of medical staff and interactions found that staff style of dress not only had no bearing on the perception of staff or visit satisfaction but that patients often failed to even accurately recall physician attire when surveyed.²⁰ Another survey study echoed these conclusions, finding that physician attire had no effect on the perception of a proposed treatment plan.²¹

What do we know about patient perception of physician attire in the dermatology setting specifically, where visits can be unique in their tendency to transition from medical to procedural in the span of a 15-minute encounter depending on the patient’s chief concern? A survey study of dermatology patients at the general, surgical, and wound care dermatology clinics of an academic medical center (Miami, Florida) found that professional attire with a white coat was strongly preferred across a litany of scenarios assessing many aspects of dermatologic care.²¹ Similarly, a study of patients visiting a single institution’s dermatology and pediatric dermatology clinics surveyed patients and parents regarding attire prior to an appointment and specifically asked if a white coat should be worn.¹³ Fifty-four percent of the adult patients (n=176) surveyed professed a preference for physicians in white coats, with a stronger preference for white coats reported by those 50 years and older (55%; n=113). Parents or guardians presenting to the pediatric dermatology clinic, on the other hand, favored less formal attire.¹³ A recent, real-world study performed at an outpatient dermatology clinic examined the influence of changing physician attire on a patient’s perceptions of care received during clinic encounters. They found no substantial difference in patient satisfaction scores before and following the adoption of a new clinic uniform that transitioned from formal attire to fitted scrubs.²²

With any study of preference, there is the underlying concern over respondent bias. Many of the studies discussed here have found secondarily that a patient’s implicit bias does not end at the clothes their physician is wearing. The survey study of dermatology patients from the academic medical center in Miami, Florida, found that patients preferred that Black physicians of either sex be garbed in professional attire at all times but generally were more accepting of White physicians in less formal attire.²¹ Adamson et al²³ published a response to the study’s findings urging dermatologists to recognize that a physician’s race and gender influence patients’ perceptions in much the same way that physician attire seems to and encouraged the development of a more diverse dermatologic workforce to help combat this prejudice. The issue of bias is not limited to the specialty of dermatology; the recent survey study by Xun et al¹⁵ found that respondents consistently rated female models garbed in physician attire as less professional than male model counterparts. Additionally, female models wearing white coats were mistakenly identified as medical technicians, physician assistants, or nurses with substantially more frequency than males, despite being clothed in the traditional physician garb. Several other publications on the subject have uncovered implicit bias, though it is rarely, if ever, the principle focus of the study.^10,24,25 As is unfortunately true in many professions, female physicians and physicians from ethnic minorities face barriers to being perceived as fully competent physicians.

Impact of the COVID-19 Pandemic

Finally, of course, there is the ever-present question of the effect of the pandemic. Although the exact role of the white coat as a fomite for infection—and especially for the spread of viral illness—remains controversial, the perception nonetheless has helped catalyze the movement to alternatives such as short-sleeved white coats, technical jackets, and more recently, fitted scrubs.^26-29 As with much in this realm, facts seem less important than perceptions; Zahrina et al³⁰ found that when patients were presented with information regarding the risk for microbial contamination associated with white coats, preference for physicians in professional garb plummeted from 72% to only 22%. To date no articles have examined patient perceptions of the white coat in the context of microbial transmission in the age of COVID-19, but future articles on this topic are likely and may serve to further the demise of the white coat.

Final Thoughts

From my vantage point, it seems the white coat will be claimed by the outgoing tide. During this most recent residency interview season, I do not recall a single medical student wearing a short white coat. The closest I came was a quick glimpse of a crumpled white jacket slung over an arm or stuffed in a shoulder bag. Rotating interns and residents from other services on rotation in our department present in softshell or fleece jackets. Fitted scrubs in the newest trendy colors speckle a previously all-white canvas. I, for one, have not donned my own white coat in at least a year, and perhaps it is all for the best. Physician attire is one small aspect of the practice of medicine and likely bears little, if any, relation to the wearer’s qualifications. Our focus should be on building rapport with our patients, providing high-quality care, reducing the risk for nosocomial infection, and developing a health care system that is fair and equitable for patients and health care workers alike, not on who is wearing what. Perhaps the introduction of new physician attire is a small part of the disruption we need to help address persistent gender and racial biases in our field and help shepherd our patients and colleagues to a worldview that is more open and accepting of physicians of diverse backgrounds.

The White Coat Ceremony is an enduring memory from my medical school years. Amidst the tumult of memories of seemingly endless sleepless nights spent in libraries and cramming for clerkship examinations between surgical cases, I recall a sunny spring day in 2016 where I gathered with my classmates, family, and friends in the medical school campus courtyard. There were several short, mostly forgotten speeches after which proud fathers and mothers, partners, or siblings slipped the all-important white coat onto the shoulders of the physicians-to-be. At that moment, I felt the weight of tradition centuries in the making resting on my shoulders. Of course, the pomp of the ceremony might have felt a tad overblown had I known that the whole thing had fewer years under its belt than the movie Die Hard.

That’s right, the first White Coat Ceremony was held 5 years after the release of that Bruce Willis classic. Dr. Arnold Gold, a pediatric neurologist on faculty at Columbia University, conceived the ceremony in 1993, and it spread rapidly to medical schools—and later nursing schools—across the United States.¹ Although the values highlighted by the White Coat Ceremony—humanism and compassion in medicine—are timeless, the ceremony itself is a more modern undertaking. What, then, of the white coat itself? Is it the timeless symbol of doctoring—of medicine—that we all presume it to be? Or is it a symbol of modern marketing, just a trend that caught on? And is it encountering its twilight—as trends often do—in the face of changing fashion and, more fundamentally, in changes to who our physicians are and to their roles in our society?

The Cleanliness of the White Coat

Until the end of the 19th century, physicians in the Western world most frequently dressed in black formal wear. The rationale behind this attire seems to have been twofold. First, society as a whole perceived the physician’s work as a serious and formal matter, and any medical encounter had to reflect the gravity of the occasion. Additionally, physicians’ visits often were a portent of impending demise, as physicians in the era prior to antibiotics and antisepsis frequently had little to offer their patients outside of—at best—anecdotal treatments and—at worst—sheer quackery.² Black may have seemed a respectful choice for patients who likely faced dire outcomes regardless of the treatment afforded.³

With the turn of the century came a new understanding of the concepts of antisepsis and disease transmission. While Joseph Lister first published on the use of antisepsis in 1867, his practices did not become commonplace until the early 1900s.⁴ Around the same time came the Flexner report,⁵ the publication of William Osler’s Principles and Practice of Medicine,⁶ and the establishment of the modern medical residency, all of which contributed to the shift from the patient’s own bedside and to the hospital as the house of medicine, with cleanliness and antisepsis as part of its core principles.⁷ The white coat arose as a symbol of purity and freedom from disease. Throughout the 20th century and into the 21st, it has remained the predominant symbol of cleanliness and professionalism for the medical practitioner.

Patient Preference of Physician Attire

Although the white coat may serve as a professional symbol and is well respected medicine, it also plays an important role in the layperson’s perception of their health care providers.⁸ There is little denying that patients prefer their physicians, almost uniformly, to wear a white coat. A systematic review of physician attire that included 30 studies mainly from North America, Europe, and the United Kingdom found that patient preference for formal attire and white coats is near universal.⁹ Patients routinely rate physicians wearing a white coat as more intelligent and trustworthy and feel more confident in the care they will receive.^10-13 They also freely admit that a physician’s appearance influences their satisfaction with their care.¹⁴ The recent adoption of the fleece, or softshell, jacket has not yet pervaded patients’ perceptions of what is considered appropriate physician attire. A 500-respondent survey found that patients were more likely to rate a model wearing a white coat as more professional and experienced compared to the same model wearing a fleece or softshell jacket or other formal attire sans white coat.¹⁵

Closer examination of the same data, however, reveals results reproduced with startling consistency across several studies, which suggest those of us adopting other attire need not dig those white coats out of the closet just yet. First, while many studies point to patient preference for white coats, this preference is uniformly strongest in older patients, beginning around age 40 years and becoming an entrenched preference in those older than 65 years.^9,14,16-18 On the other hand, younger patient populations display little to no such preference, and some studies indicate that younger patients actually prefer scrubs over formal attire in specific settings such as surgical offices, procedural spaces, or the emergency department.^12,14,19 This suggests that bias in favor of traditional physician garb may be more linked to age demographics and may continue to shift as the overall population ages. Additionally, although patients might profess a strong preference for physician attire in theory, it often does not translate into any impact on the patient’s perception of the physician following a clinic visit. The large systematic review on the topic noted that only 25% of studies that surveyed patients about a clinical visit following the encounter reported that physician attire influenced their satisfaction with that visit, suggesting that attire may be less likely to influence patients in the real-world context of receiving care.⁹ In fact, a prospective study of patient perception of medical staff and interactions found that staff style of dress not only had no bearing on the perception of staff or visit satisfaction but that patients often failed to even accurately recall physician attire when surveyed.²⁰ Another survey study echoed these conclusions, finding that physician attire had no effect on the perception of a proposed treatment plan.²¹

What do we know about patient perception of physician attire in the dermatology setting specifically, where visits can be unique in their tendency to transition from medical to procedural in the span of a 15-minute encounter depending on the patient’s chief concern? A survey study of dermatology patients at the general, surgical, and wound care dermatology clinics of an academic medical center (Miami, Florida) found that professional attire with a white coat was strongly preferred across a litany of scenarios assessing many aspects of dermatologic care.²¹ Similarly, a study of patients visiting a single institution’s dermatology and pediatric dermatology clinics surveyed patients and parents regarding attire prior to an appointment and specifically asked if a white coat should be worn.¹³ Fifty-four percent of the adult patients (n=176) surveyed professed a preference for physicians in white coats, with a stronger preference for white coats reported by those 50 years and older (55%; n=113). Parents or guardians presenting to the pediatric dermatology clinic, on the other hand, favored less formal attire.¹³ A recent, real-world study performed at an outpatient dermatology clinic examined the influence of changing physician attire on a patient’s perceptions of care received during clinic encounters. They found no substantial difference in patient satisfaction scores before and following the adoption of a new clinic uniform that transitioned from formal attire to fitted scrubs.²²

With any study of preference, there is the underlying concern over respondent bias. Many of the studies discussed here have found secondarily that a patient’s implicit bias does not end at the clothes their physician is wearing. The survey study of dermatology patients from the academic medical center in Miami, Florida, found that patients preferred that Black physicians of either sex be garbed in professional attire at all times but generally were more accepting of White physicians in less formal attire.²¹ Adamson et al²³ published a response to the study’s findings urging dermatologists to recognize that a physician’s race and gender influence patients’ perceptions in much the same way that physician attire seems to and encouraged the development of a more diverse dermatologic workforce to help combat this prejudice. The issue of bias is not limited to the specialty of dermatology; the recent survey study by Xun et al¹⁵ found that respondents consistently rated female models garbed in physician attire as less professional than male model counterparts. Additionally, female models wearing white coats were mistakenly identified as medical technicians, physician assistants, or nurses with substantially more frequency than males, despite being clothed in the traditional physician garb. Several other publications on the subject have uncovered implicit bias, though it is rarely, if ever, the principle focus of the study.^10,24,25 As is unfortunately true in many professions, female physicians and physicians from ethnic minorities face barriers to being perceived as fully competent physicians.

Impact of the COVID-19 Pandemic

Finally, of course, there is the ever-present question of the effect of the pandemic. Although the exact role of the white coat as a fomite for infection—and especially for the spread of viral illness—remains controversial, the perception nonetheless has helped catalyze the movement to alternatives such as short-sleeved white coats, technical jackets, and more recently, fitted scrubs.^26-29 As with much in this realm, facts seem less important than perceptions; Zahrina et al³⁰ found that when patients were presented with information regarding the risk for microbial contamination associated with white coats, preference for physicians in professional garb plummeted from 72% to only 22%. To date no articles have examined patient perceptions of the white coat in the context of microbial transmission in the age of COVID-19, but future articles on this topic are likely and may serve to further the demise of the white coat.

Final Thoughts

From my vantage point, it seems the white coat will be claimed by the outgoing tide. During this most recent residency interview season, I do not recall a single medical student wearing a short white coat. The closest I came was a quick glimpse of a crumpled white jacket slung over an arm or stuffed in a shoulder bag. Rotating interns and residents from other services on rotation in our department present in softshell or fleece jackets. Fitted scrubs in the newest trendy colors speckle a previously all-white canvas. I, for one, have not donned my own white coat in at least a year, and perhaps it is all for the best. Physician attire is one small aspect of the practice of medicine and likely bears little, if any, relation to the wearer’s qualifications. Our focus should be on building rapport with our patients, providing high-quality care, reducing the risk for nosocomial infection, and developing a health care system that is fair and equitable for patients and health care workers alike, not on who is wearing what. Perhaps the introduction of new physician attire is a small part of the disruption we need to help address persistent gender and racial biases in our field and help shepherd our patients and colleagues to a worldview that is more open and accepting of physicians of diverse backgrounds.

To the Editor:

Securing a dermatology residency position is extraordinarily competitive. The match rate for US allopathic seniors for dermatology is 84.7%, among the lowest of all medical specialties. Matched dermatology applicants boast a mean US Medical Licensing Examination (USMLE) Step 1 score of 248, the second highest of all specialties.¹ To gain an edge, applicants are faced with decisions regarding pursuit of dedicated research time and additional professional degrees.

We conducted a cross-sectional study to determine how many dermatology residency applicants pursue additional years of training and how this decision relates to USMLE scores and other metrics. This study was approved by the University of Michigan institutional review board. Using Electronic Residency Application Service applicant data, all applicants to the University of Michigan Medical School (Ann Arbor, Michigan) dermatology residency program for the 2018-2019 application cycle were included.

Analysis of variance was performed to determine differences in mean USMLE Step 1 scores, Step 2 Clinical Knowledge scores, and number of research experiences (eg, presentations, publications) between groups. A 2-tailed z test of independent samples was performed for individual pairwise subgroup analyses.

There were 608 (377 female, 231 male; mean age, 27.9 years) applicants from 199 different medical schools; 550 graduated with an MD degree, 40 with a DO degree, and 18 were international medical graduates (IMGs)(eg, MBBS, MBBCh, BAO, MBChB). One hundred eighty-four applicants (30.2%) pursued either a second professional degree or a dedicated research period lasting at least 12 months. Twenty-eight applicants (4.6%) obtained a master’s degree, 21 (3.5%) obtained a doctorate, and 135 (22.2%) pursued dedicated research.

Of the 40 DO applicants, 1 (2.5%) pursued dedicated research time; 0 (zero) completed a dual degree. None (zero) of the 18 IMGs pursued a dual degree or dedicated research time. When the scores of applicants who pursued additional training and the scores of applicants who did not were compared, neither mean USMLE Step 1 scores nor mean USMLE Step 2 Clinical Knowledge scores were statistically different (P=.31 and P=.44, respectively). Applicants who completed medical school in 4 years had fewer research experiences (mean [SD] experiences, 13.9 [13.2]) than students with a master’s degree (18.5 [8.4]), doctorate (24.5 [17.5]), or dedicated research time (23.9 [14.9])(P<.001).

Utilizing US News & World Report rankings (2019 Best Medical Schools: Research), we determined that 146 applicants (24.0%) attended a top 25 medical school in 2019.² Of those 146 applicants, 77 (52.7%) pursued additional training through dedicated research or a second professional degree. Only 107 of the 462 applicants (23.2%) from medical schools that were not in the top 25 as determined by the US News & World Report pursued additional training (P<.0001)(Figure).

There is sentiment among applicants that a weaker dermatology residency application can be bolstered through a dedicated research year or a second professional degree. Whether this additional training has an impact on an applicant’s chances of matching is unclear and requires further investigation. Our data showed that applicants from the top 25 medical schools were more likely to pursue additional training than graduates at other institutions. These highly ranked academic institutions might encourage students to pursue a dual degree or research fellowship. In addition, year-long research opportunities might be more available through top medical schools; these schools might be more likely to offer dual-degree programs or provide funding to support student research opportunities.

It is important to comment on the potential importance of funding to support research years; the unpaid nature of many research fellowships in dermatology tends to favor applicants from a higher socioeconomic background. In that respect, the pervasive trend of encouraging research years in dermatology might widen already apparent disparities in our field, likely impacting underrepresented minorities disproportionately.³ Importantly, students with an MD degree represent nearly all applicants who completed a dual degree or dedicated research time. This might be due to fewer opportunities available to IMGs and DO students or secondary to incentivization by MD institutions.

Our data also suggest that students who pursue additional training have academic achievement metrics similar to those who do not. Additional training might increase medical students’ debt burden, thus catering to more affluent applicants, which, in turn, might have an impact on the diversity of the dermatology residency applicant pool.

Our data come from a single institution during a single application cycle, comprising 608 applicants. Nationwide, there were 701 dermatology residency applicants for the 2018-2019 application cycle; our pool therefore represents most (86.7%) but not all applicants.

We decided to use the US News & World Report 2019 rankings to identify top medical schools. Although this ranking system is imperfect and inherently subjective, it is widely utilized by prospective applicants and administrative faculty; we deemed it the best ranking that we could utilize to identify top medical schools. Because the University of Michigan Medical School was in the top 25 of Best Medical Schools: Research, according to the US News & World Report 2019 rankings, our applicant pool might be skewed to applicants interested in a more academic, research-focused residency program.

Our study revealed that 30% (n=184) of dermatology residency applicants pursued a second professional degree or dedicated research time. There was no difference in UMLE Step 1 and Step 2 scores for those who pursued additional training compared to those who did not.

To the Editor:

Securing a dermatology residency position is extraordinarily competitive. The match rate for US allopathic seniors for dermatology is 84.7%, among the lowest of all medical specialties. Matched dermatology applicants boast a mean US Medical Licensing Examination (USMLE) Step 1 score of 248, the second highest of all specialties.¹ To gain an edge, applicants are faced with decisions regarding pursuit of dedicated research time and additional professional degrees.

We conducted a cross-sectional study to determine how many dermatology residency applicants pursue additional years of training and how this decision relates to USMLE scores and other metrics. This study was approved by the University of Michigan institutional review board. Using Electronic Residency Application Service applicant data, all applicants to the University of Michigan Medical School (Ann Arbor, Michigan) dermatology residency program for the 2018-2019 application cycle were included.

Analysis of variance was performed to determine differences in mean USMLE Step 1 scores, Step 2 Clinical Knowledge scores, and number of research experiences (eg, presentations, publications) between groups. A 2-tailed z test of independent samples was performed for individual pairwise subgroup analyses.

There were 608 (377 female, 231 male; mean age, 27.9 years) applicants from 199 different medical schools; 550 graduated with an MD degree, 40 with a DO degree, and 18 were international medical graduates (IMGs)(eg, MBBS, MBBCh, BAO, MBChB). One hundred eighty-four applicants (30.2%) pursued either a second professional degree or a dedicated research period lasting at least 12 months. Twenty-eight applicants (4.6%) obtained a master’s degree, 21 (3.5%) obtained a doctorate, and 135 (22.2%) pursued dedicated research.

Of the 40 DO applicants, 1 (2.5%) pursued dedicated research time; 0 (zero) completed a dual degree. None (zero) of the 18 IMGs pursued a dual degree or dedicated research time. When the scores of applicants who pursued additional training and the scores of applicants who did not were compared, neither mean USMLE Step 1 scores nor mean USMLE Step 2 Clinical Knowledge scores were statistically different (P=.31 and P=.44, respectively). Applicants who completed medical school in 4 years had fewer research experiences (mean [SD] experiences, 13.9 [13.2]) than students with a master’s degree (18.5 [8.4]), doctorate (24.5 [17.5]), or dedicated research time (23.9 [14.9])(P<.001).

Utilizing US News & World Report rankings (2019 Best Medical Schools: Research), we determined that 146 applicants (24.0%) attended a top 25 medical school in 2019.² Of those 146 applicants, 77 (52.7%) pursued additional training through dedicated research or a second professional degree. Only 107 of the 462 applicants (23.2%) from medical schools that were not in the top 25 as determined by the US News & World Report pursued additional training (P<.0001)(Figure).

There is sentiment among applicants that a weaker dermatology residency application can be bolstered through a dedicated research year or a second professional degree. Whether this additional training has an impact on an applicant’s chances of matching is unclear and requires further investigation. Our data showed that applicants from the top 25 medical schools were more likely to pursue additional training than graduates at other institutions. These highly ranked academic institutions might encourage students to pursue a dual degree or research fellowship. In addition, year-long research opportunities might be more available through top medical schools; these schools might be more likely to offer dual-degree programs or provide funding to support student research opportunities.

It is important to comment on the potential importance of funding to support research years; the unpaid nature of many research fellowships in dermatology tends to favor applicants from a higher socioeconomic background. In that respect, the pervasive trend of encouraging research years in dermatology might widen already apparent disparities in our field, likely impacting underrepresented minorities disproportionately.³ Importantly, students with an MD degree represent nearly all applicants who completed a dual degree or dedicated research time. This might be due to fewer opportunities available to IMGs and DO students or secondary to incentivization by MD institutions.

Our data also suggest that students who pursue additional training have academic achievement metrics similar to those who do not. Additional training might increase medical students’ debt burden, thus catering to more affluent applicants, which, in turn, might have an impact on the diversity of the dermatology residency applicant pool.

Our data come from a single institution during a single application cycle, comprising 608 applicants. Nationwide, there were 701 dermatology residency applicants for the 2018-2019 application cycle; our pool therefore represents most (86.7%) but not all applicants.

We decided to use the US News & World Report 2019 rankings to identify top medical schools. Although this ranking system is imperfect and inherently subjective, it is widely utilized by prospective applicants and administrative faculty; we deemed it the best ranking that we could utilize to identify top medical schools. Because the University of Michigan Medical School was in the top 25 of Best Medical Schools: Research, according to the US News & World Report 2019 rankings, our applicant pool might be skewed to applicants interested in a more academic, research-focused residency program.

Our study revealed that 30% (n=184) of dermatology residency applicants pursued a second professional degree or dedicated research time. There was no difference in UMLE Step 1 and Step 2 scores for those who pursued additional training compared to those who did not.

To the Editor:

Securing a dermatology residency position is extraordinarily competitive. The match rate for US allopathic seniors for dermatology is 84.7%, among the lowest of all medical specialties. Matched dermatology applicants boast a mean US Medical Licensing Examination (USMLE) Step 1 score of 248, the second highest of all specialties.¹ To gain an edge, applicants are faced with decisions regarding pursuit of dedicated research time and additional professional degrees.

We conducted a cross-sectional study to determine how many dermatology residency applicants pursue additional years of training and how this decision relates to USMLE scores and other metrics. This study was approved by the University of Michigan institutional review board. Using Electronic Residency Application Service applicant data, all applicants to the University of Michigan Medical School (Ann Arbor, Michigan) dermatology residency program for the 2018-2019 application cycle were included.

Analysis of variance was performed to determine differences in mean USMLE Step 1 scores, Step 2 Clinical Knowledge scores, and number of research experiences (eg, presentations, publications) between groups. A 2-tailed z test of independent samples was performed for individual pairwise subgroup analyses.

There were 608 (377 female, 231 male; mean age, 27.9 years) applicants from 199 different medical schools; 550 graduated with an MD degree, 40 with a DO degree, and 18 were international medical graduates (IMGs)(eg, MBBS, MBBCh, BAO, MBChB). One hundred eighty-four applicants (30.2%) pursued either a second professional degree or a dedicated research period lasting at least 12 months. Twenty-eight applicants (4.6%) obtained a master’s degree, 21 (3.5%) obtained a doctorate, and 135 (22.2%) pursued dedicated research.

Of the 40 DO applicants, 1 (2.5%) pursued dedicated research time; 0 (zero) completed a dual degree. None (zero) of the 18 IMGs pursued a dual degree or dedicated research time. When the scores of applicants who pursued additional training and the scores of applicants who did not were compared, neither mean USMLE Step 1 scores nor mean USMLE Step 2 Clinical Knowledge scores were statistically different (P=.31 and P=.44, respectively). Applicants who completed medical school in 4 years had fewer research experiences (mean [SD] experiences, 13.9 [13.2]) than students with a master’s degree (18.5 [8.4]), doctorate (24.5 [17.5]), or dedicated research time (23.9 [14.9])(P<.001).

Utilizing US News & World Report rankings (2019 Best Medical Schools: Research), we determined that 146 applicants (24.0%) attended a top 25 medical school in 2019.² Of those 146 applicants, 77 (52.7%) pursued additional training through dedicated research or a second professional degree. Only 107 of the 462 applicants (23.2%) from medical schools that were not in the top 25 as determined by the US News & World Report pursued additional training (P<.0001)(Figure).

There is sentiment among applicants that a weaker dermatology residency application can be bolstered through a dedicated research year or a second professional degree. Whether this additional training has an impact on an applicant’s chances of matching is unclear and requires further investigation. Our data showed that applicants from the top 25 medical schools were more likely to pursue additional training than graduates at other institutions. These highly ranked academic institutions might encourage students to pursue a dual degree or research fellowship. In addition, year-long research opportunities might be more available through top medical schools; these schools might be more likely to offer dual-degree programs or provide funding to support student research opportunities.

It is important to comment on the potential importance of funding to support research years; the unpaid nature of many research fellowships in dermatology tends to favor applicants from a higher socioeconomic background. In that respect, the pervasive trend of encouraging research years in dermatology might widen already apparent disparities in our field, likely impacting underrepresented minorities disproportionately.³ Importantly, students with an MD degree represent nearly all applicants who completed a dual degree or dedicated research time. This might be due to fewer opportunities available to IMGs and DO students or secondary to incentivization by MD institutions.

Our data also suggest that students who pursue additional training have academic achievement metrics similar to those who do not. Additional training might increase medical students’ debt burden, thus catering to more affluent applicants, which, in turn, might have an impact on the diversity of the dermatology residency applicant pool.

Our data come from a single institution during a single application cycle, comprising 608 applicants. Nationwide, there were 701 dermatology residency applicants for the 2018-2019 application cycle; our pool therefore represents most (86.7%) but not all applicants.

We decided to use the US News & World Report 2019 rankings to identify top medical schools. Although this ranking system is imperfect and inherently subjective, it is widely utilized by prospective applicants and administrative faculty; we deemed it the best ranking that we could utilize to identify top medical schools. Because the University of Michigan Medical School was in the top 25 of Best Medical Schools: Research, according to the US News & World Report 2019 rankings, our applicant pool might be skewed to applicants interested in a more academic, research-focused residency program.

Our study revealed that 30% (n=184) of dermatology residency applicants pursued a second professional degree or dedicated research time. There was no difference in UMLE Step 1 and Step 2 scores for those who pursued additional training compared to those who did not.

As of 2018, the mean dermatologist to population ratio in the United States was 1.10 per 100,000 people, highlighting a shortage of dermatologists that is only predicted to increase in coming years.^1-4 This undersupply is fueled by both an increasing burden of dermatologic disease and population growth.⁴ Without readily available access to dermatologic care, many patients are left waiting for weeks to see a dermatologist, depending on geographic region.^5-7 It is not simply patients who perceive wait times to be prolonged; approximately half of dermatologists surveyed by the American Academy of Dermatology (AAD) reported an undersupply of dermatologists in their communities, a finding that strongly correlated with patient wait times.² Ensuring the dermatologic workforce is sufficient to fulfill patient needs requires innovation of current practice models. To address this unmet demand, many practices have begun incorporating physician extenders, a term that encompasses physicians not board certified in dermatology, physician assistants, and nurse practitioners.⁷ The evolving landscape of the dermatologic workforce raises questions about future practice models and patient outcomes.

Scope of Practice for Physician Extenders

In practice, the role of physician extenders is highly variable. Legislation involving the scope of practice for physician extenders constantly is changing and varies by state. As of November 2021, 24 states and the District of Columbia permit nurse practitioners “full practice” authority to triage patients, interpret diagnostic tests, and prescribe treatments without physician oversight, including controlled substances.^8,9 Even in states with “reduced practice” and “restricted practice” paradigms, which necessitate physician oversight, there remains ambiguity. Across the country, state regulatory bodies differ in statues governing licensing requirements, accessibility of the supervising physician, and ultimately culpability in the case of patient harm. Lack of consensus guidelines that clearly define roles and responsibilities has kindled controversy regarding extent of autonomy and liability for adverse outcomes.^10,11

With respect to procedures, the AAD has explicitly recommended that “only active and properly licensed doctors of medicine and osteopathy shall engage in the practice of medicine” but that “under appropriate circumstances, a physician may delegate certain procedures and services to appropriately trained nonphysician office personnel.”¹² This statement does not refer to or explicitly list the procedures that are appropriate for delegation to nonphysician personnel, and there is wide variability in how this recommendation is applied in daily practice. As it was originally intended, the AAD’s “Ethics in Medical Practice” position statement indicated that dermatologists must directly oversee physician extenders, a responsibility that is defined as being “present on-site, immediately available and able to respond promptly” to issues arising during the provision of health care services.¹²

Adverse Events From Cosmetic Procedures

The American Society for Dermatologic Surgery has documented a steady growth in the demand for cosmetic, medical, and surgical services,¹³ a trend that has heralded an increase in the number of procedures performed by physician extenders.^14,15 One study contrasted the risk for adverse events following minimally invasive cosmetic procedures performed by physicians or nonphysicians. Of 2116 patients surveyed, 50 adverse events were documented.¹⁴ The cohort treated by nonphysicians experienced a higher incidence of laser burns and dyspigmentation, and the use of improper technique was the most frequently implicated cause of developing an adverse event. Approximately 24.6% of American Society for Dermatologic Surgery members reported treating 10 or more complications of cosmetic procedures performed by nonphysicians.¹⁴ Beyond laser burns and dyspigmentation, this wide range of complications included inappropriately placed filler product, facial drooping, and scarring. These studies highlight the need for further investigation into the outcomes of procedures performed by physician extenders.

Training of Physician Extenders

Even with medical management, emphasis on proper training of personnel is key and remains a legitimate concern. The training of physician extenders in dermatology differs greatly by location; while some physician extenders operate under meticulous guidance and thus can expand their skill set, other physician extenders shadow dermatologists for an arbitrary amount of time before being thrust into practice.¹⁰ It would be a disservice to both patients and nonphysician providers alike to conflate the latter regimen with the 4 years of medical school, 1 year of internship, and 3 years of rigorous specialized dermatologic training that physicians undergo.

This stark discrepancy between the training of physicians and physician extenders raises difficult questions about the patient’s right to make an informed decision regarding how they receive health care. Indeed, the casually regulated autonomous practice of some nonphysician providers has ignited public shock and ire.¹¹

Reducing Health Care Expenditures

As legislatures deliberate over expanding scope of practice, policies should be based on evidence that prioritizes patient safety. In the appropriate setting, physician extenders can be instrumental to mitigating health care disparities; the use of physician extenders can diminish wait times for patients with routine visits for stable dermatologic disease.¹⁶ Moreover, reducing health care expenditures often is cited as a major benefit of increased utilization of physician extenders.¹⁴ It stands to reason that compensation of nonphysician providers is less expensive for a practice compared with physicians. Physician extenders participating in the management of stable chronic conditions or mild acute conditions may be cost-efficient in these circumstances; however, evidence suggests that physician extenders may incur greater costs than physicians with respect to the utilization of diagnostic tests or prescribing medications. For example, several studies have documented a substantial difference in the number of biopsies needed per malignant neoplasm by physicians compared to physician extenders.^17-19 Particularly in patients younger than 65 years and in patients without history of skin cancer, physician extenders had to perform a greater number of biopsies to diagnose malignant neoplasms vs physicians.¹⁸ In addition to increased utilization of diagnostic tests, nonphysician providers more frequently prescribe medications of varying classes.^20-22 Whether in outpatient offices, emergency departments, or hospital clinics, physician extenders more frequently prescribe antibiotics, which has concerning implications for antibiotic stewardship.^20,21 In states with independent prescription authority, physician extenders are more than 20 times more likely to overprescribeopioids compared to physician extenders in states requiring physician supervision.²³ These findings warrant additional investigation into how prescription patterns vary by provider type and how these differences impact patient outcomes.

Final Thoughts

Improving patient care is inherently a team endeavor, and the contributions of all members of the health care team are critical to success. Engaging physician extenders may help mitigate disparities in dermatologic care, with respect to surveillance of stable chronic conditions or the diagnosis of mild acute diseases. However, the exact scope of practice of physician extenders remains ambiguous, and their training regimens can vary drastically. Therefore, in the interest of patient safety, new patients or medically complex patients (ie, cutaneous lymphomas, nonstable autoimmune connective tissue disease) should be examined and managed by physicians. In either scenario, the patient should be informed of which providers are available and should be integrated into the decision-making process for their care. Through mutual respect, close collaboration, and candid assessments of patient complexity, different parties within the medical team can unite behind the mission to improve patient outcomes and champion equitable access to health care.

As of 2018, the mean dermatologist to population ratio in the United States was 1.10 per 100,000 people, highlighting a shortage of dermatologists that is only predicted to increase in coming years.^1-4 This undersupply is fueled by both an increasing burden of dermatologic disease and population growth.⁴ Without readily available access to dermatologic care, many patients are left waiting for weeks to see a dermatologist, depending on geographic region.^5-7 It is not simply patients who perceive wait times to be prolonged; approximately half of dermatologists surveyed by the American Academy of Dermatology (AAD) reported an undersupply of dermatologists in their communities, a finding that strongly correlated with patient wait times.² Ensuring the dermatologic workforce is sufficient to fulfill patient needs requires innovation of current practice models. To address this unmet demand, many practices have begun incorporating physician extenders, a term that encompasses physicians not board certified in dermatology, physician assistants, and nurse practitioners.⁷ The evolving landscape of the dermatologic workforce raises questions about future practice models and patient outcomes.

Scope of Practice for Physician Extenders

In practice, the role of physician extenders is highly variable. Legislation involving the scope of practice for physician extenders constantly is changing and varies by state. As of November 2021, 24 states and the District of Columbia permit nurse practitioners “full practice” authority to triage patients, interpret diagnostic tests, and prescribe treatments without physician oversight, including controlled substances.^8,9 Even in states with “reduced practice” and “restricted practice” paradigms, which necessitate physician oversight, there remains ambiguity. Across the country, state regulatory bodies differ in statues governing licensing requirements, accessibility of the supervising physician, and ultimately culpability in the case of patient harm. Lack of consensus guidelines that clearly define roles and responsibilities has kindled controversy regarding extent of autonomy and liability for adverse outcomes.^10,11

With respect to procedures, the AAD has explicitly recommended that “only active and properly licensed doctors of medicine and osteopathy shall engage in the practice of medicine” but that “under appropriate circumstances, a physician may delegate certain procedures and services to appropriately trained nonphysician office personnel.”¹² This statement does not refer to or explicitly list the procedures that are appropriate for delegation to nonphysician personnel, and there is wide variability in how this recommendation is applied in daily practice. As it was originally intended, the AAD’s “Ethics in Medical Practice” position statement indicated that dermatologists must directly oversee physician extenders, a responsibility that is defined as being “present on-site, immediately available and able to respond promptly” to issues arising during the provision of health care services.¹²

Adverse Events From Cosmetic Procedures

The American Society for Dermatologic Surgery has documented a steady growth in the demand for cosmetic, medical, and surgical services,¹³ a trend that has heralded an increase in the number of procedures performed by physician extenders.^14,15 One study contrasted the risk for adverse events following minimally invasive cosmetic procedures performed by physicians or nonphysicians. Of 2116 patients surveyed, 50 adverse events were documented.¹⁴ The cohort treated by nonphysicians experienced a higher incidence of laser burns and dyspigmentation, and the use of improper technique was the most frequently implicated cause of developing an adverse event. Approximately 24.6% of American Society for Dermatologic Surgery members reported treating 10 or more complications of cosmetic procedures performed by nonphysicians.¹⁴ Beyond laser burns and dyspigmentation, this wide range of complications included inappropriately placed filler product, facial drooping, and scarring. These studies highlight the need for further investigation into the outcomes of procedures performed by physician extenders.

Training of Physician Extenders

Even with medical management, emphasis on proper training of personnel is key and remains a legitimate concern. The training of physician extenders in dermatology differs greatly by location; while some physician extenders operate under meticulous guidance and thus can expand their skill set, other physician extenders shadow dermatologists for an arbitrary amount of time before being thrust into practice.¹⁰ It would be a disservice to both patients and nonphysician providers alike to conflate the latter regimen with the 4 years of medical school, 1 year of internship, and 3 years of rigorous specialized dermatologic training that physicians undergo.

This stark discrepancy between the training of physicians and physician extenders raises difficult questions about the patient’s right to make an informed decision regarding how they receive health care. Indeed, the casually regulated autonomous practice of some nonphysician providers has ignited public shock and ire.¹¹

Reducing Health Care Expenditures

As legislatures deliberate over expanding scope of practice, policies should be based on evidence that prioritizes patient safety. In the appropriate setting, physician extenders can be instrumental to mitigating health care disparities; the use of physician extenders can diminish wait times for patients with routine visits for stable dermatologic disease.¹⁶ Moreover, reducing health care expenditures often is cited as a major benefit of increased utilization of physician extenders.¹⁴ It stands to reason that compensation of nonphysician providers is less expensive for a practice compared with physicians. Physician extenders participating in the management of stable chronic conditions or mild acute conditions may be cost-efficient in these circumstances; however, evidence suggests that physician extenders may incur greater costs than physicians with respect to the utilization of diagnostic tests or prescribing medications. For example, several studies have documented a substantial difference in the number of biopsies needed per malignant neoplasm by physicians compared to physician extenders.^17-19 Particularly in patients younger than 65 years and in patients without history of skin cancer, physician extenders had to perform a greater number of biopsies to diagnose malignant neoplasms vs physicians.¹⁸ In addition to increased utilization of diagnostic tests, nonphysician providers more frequently prescribe medications of varying classes.^20-22 Whether in outpatient offices, emergency departments, or hospital clinics, physician extenders more frequently prescribe antibiotics, which has concerning implications for antibiotic stewardship.^20,21 In states with independent prescription authority, physician extenders are more than 20 times more likely to overprescribeopioids compared to physician extenders in states requiring physician supervision.²³ These findings warrant additional investigation into how prescription patterns vary by provider type and how these differences impact patient outcomes.

Final Thoughts

Improving patient care is inherently a team endeavor, and the contributions of all members of the health care team are critical to success. Engaging physician extenders may help mitigate disparities in dermatologic care, with respect to surveillance of stable chronic conditions or the diagnosis of mild acute diseases. However, the exact scope of practice of physician extenders remains ambiguous, and their training regimens can vary drastically. Therefore, in the interest of patient safety, new patients or medically complex patients (ie, cutaneous lymphomas, nonstable autoimmune connective tissue disease) should be examined and managed by physicians. In either scenario, the patient should be informed of which providers are available and should be integrated into the decision-making process for their care. Through mutual respect, close collaboration, and candid assessments of patient complexity, different parties within the medical team can unite behind the mission to improve patient outcomes and champion equitable access to health care.

As of 2018, the mean dermatologist to population ratio in the United States was 1.10 per 100,000 people, highlighting a shortage of dermatologists that is only predicted to increase in coming years.^1-4 This undersupply is fueled by both an increasing burden of dermatologic disease and population growth.⁴ Without readily available access to dermatologic care, many patients are left waiting for weeks to see a dermatologist, depending on geographic region.^5-7 It is not simply patients who perceive wait times to be prolonged; approximately half of dermatologists surveyed by the American Academy of Dermatology (AAD) reported an undersupply of dermatologists in their communities, a finding that strongly correlated with patient wait times.² Ensuring the dermatologic workforce is sufficient to fulfill patient needs requires innovation of current practice models. To address this unmet demand, many practices have begun incorporating physician extenders, a term that encompasses physicians not board certified in dermatology, physician assistants, and nurse practitioners.⁷ The evolving landscape of the dermatologic workforce raises questions about future practice models and patient outcomes.

Scope of Practice for Physician Extenders

In practice, the role of physician extenders is highly variable. Legislation involving the scope of practice for physician extenders constantly is changing and varies by state. As of November 2021, 24 states and the District of Columbia permit nurse practitioners “full practice” authority to triage patients, interpret diagnostic tests, and prescribe treatments without physician oversight, including controlled substances.^8,9 Even in states with “reduced practice” and “restricted practice” paradigms, which necessitate physician oversight, there remains ambiguity. Across the country, state regulatory bodies differ in statues governing licensing requirements, accessibility of the supervising physician, and ultimately culpability in the case of patient harm. Lack of consensus guidelines that clearly define roles and responsibilities has kindled controversy regarding extent of autonomy and liability for adverse outcomes.^10,11

With respect to procedures, the AAD has explicitly recommended that “only active and properly licensed doctors of medicine and osteopathy shall engage in the practice of medicine” but that “under appropriate circumstances, a physician may delegate certain procedures and services to appropriately trained nonphysician office personnel.”¹² This statement does not refer to or explicitly list the procedures that are appropriate for delegation to nonphysician personnel, and there is wide variability in how this recommendation is applied in daily practice. As it was originally intended, the AAD’s “Ethics in Medical Practice” position statement indicated that dermatologists must directly oversee physician extenders, a responsibility that is defined as being “present on-site, immediately available and able to respond promptly” to issues arising during the provision of health care services.¹²

Adverse Events From Cosmetic Procedures

The American Society for Dermatologic Surgery has documented a steady growth in the demand for cosmetic, medical, and surgical services,¹³ a trend that has heralded an increase in the number of procedures performed by physician extenders.^14,15 One study contrasted the risk for adverse events following minimally invasive cosmetic procedures performed by physicians or nonphysicians. Of 2116 patients surveyed, 50 adverse events were documented.¹⁴ The cohort treated by nonphysicians experienced a higher incidence of laser burns and dyspigmentation, and the use of improper technique was the most frequently implicated cause of developing an adverse event. Approximately 24.6% of American Society for Dermatologic Surgery members reported treating 10 or more complications of cosmetic procedures performed by nonphysicians.¹⁴ Beyond laser burns and dyspigmentation, this wide range of complications included inappropriately placed filler product, facial drooping, and scarring. These studies highlight the need for further investigation into the outcomes of procedures performed by physician extenders.

Training of Physician Extenders

Even with medical management, emphasis on proper training of personnel is key and remains a legitimate concern. The training of physician extenders in dermatology differs greatly by location; while some physician extenders operate under meticulous guidance and thus can expand their skill set, other physician extenders shadow dermatologists for an arbitrary amount of time before being thrust into practice.¹⁰ It would be a disservice to both patients and nonphysician providers alike to conflate the latter regimen with the 4 years of medical school, 1 year of internship, and 3 years of rigorous specialized dermatologic training that physicians undergo.

This stark discrepancy between the training of physicians and physician extenders raises difficult questions about the patient’s right to make an informed decision regarding how they receive health care. Indeed, the casually regulated autonomous practice of some nonphysician providers has ignited public shock and ire.¹¹

Reducing Health Care Expenditures

As legislatures deliberate over expanding scope of practice, policies should be based on evidence that prioritizes patient safety. In the appropriate setting, physician extenders can be instrumental to mitigating health care disparities; the use of physician extenders can diminish wait times for patients with routine visits for stable dermatologic disease.¹⁶ Moreover, reducing health care expenditures often is cited as a major benefit of increased utilization of physician extenders.¹⁴ It stands to reason that compensation of nonphysician providers is less expensive for a practice compared with physicians. Physician extenders participating in the management of stable chronic conditions or mild acute conditions may be cost-efficient in these circumstances; however, evidence suggests that physician extenders may incur greater costs than physicians with respect to the utilization of diagnostic tests or prescribing medications. For example, several studies have documented a substantial difference in the number of biopsies needed per malignant neoplasm by physicians compared to physician extenders.^17-19 Particularly in patients younger than 65 years and in patients without history of skin cancer, physician extenders had to perform a greater number of biopsies to diagnose malignant neoplasms vs physicians.¹⁸ In addition to increased utilization of diagnostic tests, nonphysician providers more frequently prescribe medications of varying classes.^20-22 Whether in outpatient offices, emergency departments, or hospital clinics, physician extenders more frequently prescribe antibiotics, which has concerning implications for antibiotic stewardship.^20,21 In states with independent prescription authority, physician extenders are more than 20 times more likely to overprescribeopioids compared to physician extenders in states requiring physician supervision.²³ These findings warrant additional investigation into how prescription patterns vary by provider type and how these differences impact patient outcomes.

Final Thoughts

Improving patient care is inherently a team endeavor, and the contributions of all members of the health care team are critical to success. Engaging physician extenders may help mitigate disparities in dermatologic care, with respect to surveillance of stable chronic conditions or the diagnosis of mild acute diseases. However, the exact scope of practice of physician extenders remains ambiguous, and their training regimens can vary drastically. Therefore, in the interest of patient safety, new patients or medically complex patients (ie, cutaneous lymphomas, nonstable autoimmune connective tissue disease) should be examined and managed by physicians. In either scenario, the patient should be informed of which providers are available and should be integrated into the decision-making process for their care. Through mutual respect, close collaboration, and candid assessments of patient complexity, different parties within the medical team can unite behind the mission to improve patient outcomes and champion equitable access to health care.

Rheumatologists seeking fellowships continue to show a preference for adult programs. Adult rheumatology programs filled nearly 100% of positions this year, but pediatric rheumatology programs filled only 69% of available slots, echoing trends of previous years.

The National Resident Matching Program (NRMP) issued results for 2021’s Medical Specialties Matching Program (MSMP) and Pediatric Specialties Match (PSM) in December.

“In pediatric rheumatology, like many other pediatric specialties, the limiting factor is the number of interested candidates. The number of available positions has not really changed over the last several years, but multiple positions again remained unfilled this year,” said Beth Marston, MD, chair of the American College of Rheumatology’s Committee on Rheumatology Training and Workforce Issues, in a statement.

Rheumatology was one of seven medical specialties that filled at least 95% of fellowship positions this year.

The specialty filled 120 of 125 enrolled programs (96%) and 266 of 272 certified positions (97.8%) in 2021. A total of 42.1% of the matched applicants comprised MD graduates, followed by foreign (27.1%), U.S. foreign (16.5%), and DO graduates (14.3%).

Among 357 applicants preferring this specialty in 2021, 73.9% (n = 264) matched to rheumatology. This meant that 22.1% did not match to any program. This scenario has played out over the last several years, Dr. Marston noted. Additional support for funding and the creation of more fellowship positions would translate to an increase in rheumatology graduates entering the workforce.

This could help mitigate workforce shortages that the ACR projected in 2015, she added.

Pediatric program applicants remain stagnant

For pediatric fellowships, the numbers weren’t as robust. Just 60% of 32 enrolled programs and 69.2% positions filled in 2021. MD graduates comprised most of the matched applicants (77.8%), followed by U.S. foreign (14.8%) and foreign and DO graduates (3.7% each). Overall, 27 out of 28 applicants or 96.4% matched to this specialty, a metric that’s remained steady but has not grown in recent years, Dr. Marston said.

This “suggests the need for additional efforts to understand and address barriers to choosing rheumatology fellowship training as a career path for pediatricians,” she said. The ACR’s Committee on Training and Workforce recently initiated a survey of combined medicine-pediatrics graduates in rheumatology to gain insights on why these graduates chose this career path.

The ACR is also looking into increasing access to rheumatology specialty care in underserved areas and finding creative solutions for increasing and filling rheumatology fellowship positions.
 

Largest match on record

Overall, 7,435 applicants participated in the 2021 MSMP, the largest on record. NRMP reported that 2,277 programs submitted rank order lists and offered 6,368 positions, an increase of more than 11% from 2020, respectively. A total of 90.4% positions (n = 5,759) were filled.

“The 2021 MSMP matched a record number of applicants to subspecialty training programs for positions set to begin July 2022,” NRMP President and CEO Donna L. Lamb, DHSc, MBA, said in a statement. “It’s rewarding to watch the MSMP grow, not only in terms of applicant interest and available training positions, but also from its launch 20 years ago with only three internal medicine subspecialties.”

NRMP largely attributed the increase in positions to the addition of critical care medicine, the latest subspecialty to join the MSMP. All fellows begin their training in July 2022.

The PSM also saw notable increases this year in several metrics. It offered 1,735 positions this year, a 5.9% increase from 2020. Overall, 1,507 positions (86.9%) were filled, a 6.6% increase from last year. 854 programs participated.

Rheumatologists seeking fellowships continue to show a preference for adult programs. Adult rheumatology programs filled nearly 100% of positions this year, but pediatric rheumatology programs filled only 69% of available slots, echoing trends of previous years.

The National Resident Matching Program (NRMP) issued results for 2021’s Medical Specialties Matching Program (MSMP) and Pediatric Specialties Match (PSM) in December.

“In pediatric rheumatology, like many other pediatric specialties, the limiting factor is the number of interested candidates. The number of available positions has not really changed over the last several years, but multiple positions again remained unfilled this year,” said Beth Marston, MD, chair of the American College of Rheumatology’s Committee on Rheumatology Training and Workforce Issues, in a statement.

Rheumatology was one of seven medical specialties that filled at least 95% of fellowship positions this year.

The specialty filled 120 of 125 enrolled programs (96%) and 266 of 272 certified positions (97.8%) in 2021. A total of 42.1% of the matched applicants comprised MD graduates, followed by foreign (27.1%), U.S. foreign (16.5%), and DO graduates (14.3%).

Among 357 applicants preferring this specialty in 2021, 73.9% (n = 264) matched to rheumatology. This meant that 22.1% did not match to any program. This scenario has played out over the last several years, Dr. Marston noted. Additional support for funding and the creation of more fellowship positions would translate to an increase in rheumatology graduates entering the workforce.

This could help mitigate workforce shortages that the ACR projected in 2015, she added.

Pediatric program applicants remain stagnant

For pediatric fellowships, the numbers weren’t as robust. Just 60% of 32 enrolled programs and 69.2% positions filled in 2021. MD graduates comprised most of the matched applicants (77.8%), followed by U.S. foreign (14.8%) and foreign and DO graduates (3.7% each). Overall, 27 out of 28 applicants or 96.4% matched to this specialty, a metric that’s remained steady but has not grown in recent years, Dr. Marston said.

This “suggests the need for additional efforts to understand and address barriers to choosing rheumatology fellowship training as a career path for pediatricians,” she said. The ACR’s Committee on Training and Workforce recently initiated a survey of combined medicine-pediatrics graduates in rheumatology to gain insights on why these graduates chose this career path.

The ACR is also looking into increasing access to rheumatology specialty care in underserved areas and finding creative solutions for increasing and filling rheumatology fellowship positions.
 

Largest match on record

Overall, 7,435 applicants participated in the 2021 MSMP, the largest on record. NRMP reported that 2,277 programs submitted rank order lists and offered 6,368 positions, an increase of more than 11% from 2020, respectively. A total of 90.4% positions (n = 5,759) were filled.

“The 2021 MSMP matched a record number of applicants to subspecialty training programs for positions set to begin July 2022,” NRMP President and CEO Donna L. Lamb, DHSc, MBA, said in a statement. “It’s rewarding to watch the MSMP grow, not only in terms of applicant interest and available training positions, but also from its launch 20 years ago with only three internal medicine subspecialties.”

NRMP largely attributed the increase in positions to the addition of critical care medicine, the latest subspecialty to join the MSMP. All fellows begin their training in July 2022.

The PSM also saw notable increases this year in several metrics. It offered 1,735 positions this year, a 5.9% increase from 2020. Overall, 1,507 positions (86.9%) were filled, a 6.6% increase from last year. 854 programs participated.

Rheumatologists seeking fellowships continue to show a preference for adult programs. Adult rheumatology programs filled nearly 100% of positions this year, but pediatric rheumatology programs filled only 69% of available slots, echoing trends of previous years.

The National Resident Matching Program (NRMP) issued results for 2021’s Medical Specialties Matching Program (MSMP) and Pediatric Specialties Match (PSM) in December.

“In pediatric rheumatology, like many other pediatric specialties, the limiting factor is the number of interested candidates. The number of available positions has not really changed over the last several years, but multiple positions again remained unfilled this year,” said Beth Marston, MD, chair of the American College of Rheumatology’s Committee on Rheumatology Training and Workforce Issues, in a statement.

Rheumatology was one of seven medical specialties that filled at least 95% of fellowship positions this year.

The specialty filled 120 of 125 enrolled programs (96%) and 266 of 272 certified positions (97.8%) in 2021. A total of 42.1% of the matched applicants comprised MD graduates, followed by foreign (27.1%), U.S. foreign (16.5%), and DO graduates (14.3%).

Among 357 applicants preferring this specialty in 2021, 73.9% (n = 264) matched to rheumatology. This meant that 22.1% did not match to any program. This scenario has played out over the last several years, Dr. Marston noted. Additional support for funding and the creation of more fellowship positions would translate to an increase in rheumatology graduates entering the workforce.

This could help mitigate workforce shortages that the ACR projected in 2015, she added.

Pediatric program applicants remain stagnant

For pediatric fellowships, the numbers weren’t as robust. Just 60% of 32 enrolled programs and 69.2% positions filled in 2021. MD graduates comprised most of the matched applicants (77.8%), followed by U.S. foreign (14.8%) and foreign and DO graduates (3.7% each). Overall, 27 out of 28 applicants or 96.4% matched to this specialty, a metric that’s remained steady but has not grown in recent years, Dr. Marston said.

This “suggests the need for additional efforts to understand and address barriers to choosing rheumatology fellowship training as a career path for pediatricians,” she said. The ACR’s Committee on Training and Workforce recently initiated a survey of combined medicine-pediatrics graduates in rheumatology to gain insights on why these graduates chose this career path.

The ACR is also looking into increasing access to rheumatology specialty care in underserved areas and finding creative solutions for increasing and filling rheumatology fellowship positions.
 

Largest match on record

Overall, 7,435 applicants participated in the 2021 MSMP, the largest on record. NRMP reported that 2,277 programs submitted rank order lists and offered 6,368 positions, an increase of more than 11% from 2020, respectively. A total of 90.4% positions (n = 5,759) were filled.

“The 2021 MSMP matched a record number of applicants to subspecialty training programs for positions set to begin July 2022,” NRMP President and CEO Donna L. Lamb, DHSc, MBA, said in a statement. “It’s rewarding to watch the MSMP grow, not only in terms of applicant interest and available training positions, but also from its launch 20 years ago with only three internal medicine subspecialties.”

NRMP largely attributed the increase in positions to the addition of critical care medicine, the latest subspecialty to join the MSMP. All fellows begin their training in July 2022.

The PSM also saw notable increases this year in several metrics. It offered 1,735 positions this year, a 5.9% increase from 2020. Overall, 1,507 positions (86.9%) were filled, a 6.6% increase from last year. 854 programs participated.

I had seen many new and exciting presentations of psychopathology during my intern year, yet one patient was uniquely memorable. When stable, he worked as a counselor, though for any number of reasons (eg, missing a dose of medication, smoking marijuana) his manic symptoms would emerge quickly, the disease rearing its ugly head within hours. He would become extremely hyperactive, elated, disinhibited (running naked in the streets), and grandiose (believing he was working for the president). He would be escorted to our psychiatric emergency department (ED) by police, who would have to resort to handcuffing him. His symptoms were described by ED and inpatient nursing staff and residents as “disorganized,” “psychotic,” “agitated,”’ or “combative.” He would receive large doses of intramuscular (IM) haloperidol, chlorpromazine, and diphenhydramine in desperate attempts to rein in his mania. Frustratingly—and paradoxically— this would make him more confused, disoriented, restless, and hyperactive, and often led to the need for restraints.

This behavior persisted for days until an attending I was working with assessed him. The attending observed that the patient did not know his current location, day of the week or month, or how he ended up in the hospital. He observed this patient intermittently staring, making abnormal repetitive movements with his arms and hands, occasionally freezing, making impulsive movements, and becoming combative without provocation. His heart rate and temperature were elevated; he was diaphoretic, especially after receiving parenteral antipsychotics. The attending, a pupil of Max Fink, made the diagnosis: delirious mania, a form of catatonia.^1,2 Resolution was quick and complete after 6 bilateral electroconvulsive therapy (ECT) sessions.

Catatonia, a neuropsychiatric phenomenon characterized by abnormal speech, movement, and affect, has undergone numerous paradigm shifts since it was recognized by Karl Ludwig Kahlbaum in 1874.³ Shortly after Kahlbaum, Emil Kraepelin held the belief that catatonia was a subtype of dementia praecox, or what is now known as schizophrenia.⁴ Due to this, patients were likely receiving less-than-optimal treatments, because their catatonia was being diagnosed as acute psychosis. Finally, in DSM-5, catatonia was unshackled from the constraints of schizophrenia and is now an entity of its own.⁵ However, catatonia is often met with incertitude (despite being present in up to 15% of inpatients),¹ with its treatment typically delayed or not even pursued. This is amplified because many forms of catatonia are often misdiagnosed as disorders that are more common or better understood.

Potential catatonia presentations

Delirious mania. Patients with delirious mania typically present with acute delirium, severe paranoia, hyperactivity, and visual/auditory hallucinations.^2,6,7 They usually have excited catatonic signs, such as excessive movement, combativeness, impulsivity, stereotypy, and echophenomena. Unfortunately, the catatonia is overshadowed by extreme psychotic and manic symptoms, or delirium (for which an underlying medical cause is usually not found). As was the case for the patient I described earlier, large doses of IM antipsychotics usually are administered, which can cause neuroleptic malignant syndrome (NMS) or precipitate seizures.⁸

Neuroleptic malignant syndrome. NMS is marked by fever, elevated blood pressure and heart rate, lead-pipe rigidity, parkinsonian features, altered mental status, and lab abnormalities (elevated liver enzymes or creatinine phosphokinase). This syndrome is preceded by the administration of an antipsychotic. It has features of catatonia that include mutism, negativism, and posturing.⁹ NMS is commonly interpreted as a subtype of malignant catatonia. Some argue that the diagnosis of malignant catatonia yields a more favorable outcome because it leads to more effective treatments (ie, benzodiazepines and ECT as opposed to dopamine agonists and dantrolene).¹⁰ Because NMS has much overlap with serotonin syndrome and drug-induced parkinsonism, initiation of benzodiazepines and ECT often is delayed.¹¹

Retarded catatonia. This version of catatonia usually is well recognized. The typical presentation is a patient who does not speak (mutism) or move (stupor), stares, becomes withdrawn (does not eat or drink), or maintains abnormal posturing. Retarded catatonia can be confused with a major depressive episode or hypoactive delirium.

Catatonia in autism spectrum disorder. Historically, co-occurring catatonia and autism spectrum disorder (ASD) was believed to be extremely rare. However, recent retrospective studies have found that up to 17% of patients with ASD older than age 15 have catatonia.¹² Many pediatric psychiatrists fail to recognize catatonia; in 1 study, only 2 patients (of 18) were correctly identified as having catatonia.¹³ The catatonic signs may vary, but the core features include withdrawal (children may need a feeding tube), decreased communication and/or worsening psychomotor slowing, agitation, or stereotypical movements, which can manifest as worsening self-injurious behavior.^14,15

An approach to treatment

Regardless of the etiology or presentation, first-line treatment for catatonia is benzodiazepines and/or ECT. A lorazepam challenge is used for diagnostic clarification; if effective, lorazepam can be titrated until symptoms fully resolve.^16,17 Doses >20 mg have been reported as effective and well-tolerated, without the feared sedation and respiratory depression.⁶ An unsuccessful lorazepam challenge does not rule out catatonia. If benzodiazepine therapy fails or the patient requires immediate symptom relief, ECT is the most effective treatment. Many clinicians use a bilateral electrode placement with high-energy dosing and frequent sessions until the catatonia resolves.^1,18

In my experience, catatonia in all its forms remains poorly recognized, with its treatment questioned. Residents—especially those in psychiatry—must understand that catatonia can result in systemic illness or death.

I had seen many new and exciting presentations of psychopathology during my intern year, yet one patient was uniquely memorable. When stable, he worked as a counselor, though for any number of reasons (eg, missing a dose of medication, smoking marijuana) his manic symptoms would emerge quickly, the disease rearing its ugly head within hours. He would become extremely hyperactive, elated, disinhibited (running naked in the streets), and grandiose (believing he was working for the president). He would be escorted to our psychiatric emergency department (ED) by police, who would have to resort to handcuffing him. His symptoms were described by ED and inpatient nursing staff and residents as “disorganized,” “psychotic,” “agitated,”’ or “combative.” He would receive large doses of intramuscular (IM) haloperidol, chlorpromazine, and diphenhydramine in desperate attempts to rein in his mania. Frustratingly—and paradoxically— this would make him more confused, disoriented, restless, and hyperactive, and often led to the need for restraints.

This behavior persisted for days until an attending I was working with assessed him. The attending observed that the patient did not know his current location, day of the week or month, or how he ended up in the hospital. He observed this patient intermittently staring, making abnormal repetitive movements with his arms and hands, occasionally freezing, making impulsive movements, and becoming combative without provocation. His heart rate and temperature were elevated; he was diaphoretic, especially after receiving parenteral antipsychotics. The attending, a pupil of Max Fink, made the diagnosis: delirious mania, a form of catatonia.^1,2 Resolution was quick and complete after 6 bilateral electroconvulsive therapy (ECT) sessions.

Catatonia, a neuropsychiatric phenomenon characterized by abnormal speech, movement, and affect, has undergone numerous paradigm shifts since it was recognized by Karl Ludwig Kahlbaum in 1874.³ Shortly after Kahlbaum, Emil Kraepelin held the belief that catatonia was a subtype of dementia praecox, or what is now known as schizophrenia.⁴ Due to this, patients were likely receiving less-than-optimal treatments, because their catatonia was being diagnosed as acute psychosis. Finally, in DSM-5, catatonia was unshackled from the constraints of schizophrenia and is now an entity of its own.⁵ However, catatonia is often met with incertitude (despite being present in up to 15% of inpatients),¹ with its treatment typically delayed or not even pursued. This is amplified because many forms of catatonia are often misdiagnosed as disorders that are more common or better understood.

Potential catatonia presentations

Delirious mania. Patients with delirious mania typically present with acute delirium, severe paranoia, hyperactivity, and visual/auditory hallucinations.^2,6,7 They usually have excited catatonic signs, such as excessive movement, combativeness, impulsivity, stereotypy, and echophenomena. Unfortunately, the catatonia is overshadowed by extreme psychotic and manic symptoms, or delirium (for which an underlying medical cause is usually not found). As was the case for the patient I described earlier, large doses of IM antipsychotics usually are administered, which can cause neuroleptic malignant syndrome (NMS) or precipitate seizures.⁸

Neuroleptic malignant syndrome. NMS is marked by fever, elevated blood pressure and heart rate, lead-pipe rigidity, parkinsonian features, altered mental status, and lab abnormalities (elevated liver enzymes or creatinine phosphokinase). This syndrome is preceded by the administration of an antipsychotic. It has features of catatonia that include mutism, negativism, and posturing.⁹ NMS is commonly interpreted as a subtype of malignant catatonia. Some argue that the diagnosis of malignant catatonia yields a more favorable outcome because it leads to more effective treatments (ie, benzodiazepines and ECT as opposed to dopamine agonists and dantrolene).¹⁰ Because NMS has much overlap with serotonin syndrome and drug-induced parkinsonism, initiation of benzodiazepines and ECT often is delayed.¹¹

Retarded catatonia. This version of catatonia usually is well recognized. The typical presentation is a patient who does not speak (mutism) or move (stupor), stares, becomes withdrawn (does not eat or drink), or maintains abnormal posturing. Retarded catatonia can be confused with a major depressive episode or hypoactive delirium.

Catatonia in autism spectrum disorder. Historically, co-occurring catatonia and autism spectrum disorder (ASD) was believed to be extremely rare. However, recent retrospective studies have found that up to 17% of patients with ASD older than age 15 have catatonia.¹² Many pediatric psychiatrists fail to recognize catatonia; in 1 study, only 2 patients (of 18) were correctly identified as having catatonia.¹³ The catatonic signs may vary, but the core features include withdrawal (children may need a feeding tube), decreased communication and/or worsening psychomotor slowing, agitation, or stereotypical movements, which can manifest as worsening self-injurious behavior.^14,15

An approach to treatment

Regardless of the etiology or presentation, first-line treatment for catatonia is benzodiazepines and/or ECT. A lorazepam challenge is used for diagnostic clarification; if effective, lorazepam can be titrated until symptoms fully resolve.^16,17 Doses >20 mg have been reported as effective and well-tolerated, without the feared sedation and respiratory depression.⁶ An unsuccessful lorazepam challenge does not rule out catatonia. If benzodiazepine therapy fails or the patient requires immediate symptom relief, ECT is the most effective treatment. Many clinicians use a bilateral electrode placement with high-energy dosing and frequent sessions until the catatonia resolves.^1,18

In my experience, catatonia in all its forms remains poorly recognized, with its treatment questioned. Residents—especially those in psychiatry—must understand that catatonia can result in systemic illness or death.

I had seen many new and exciting presentations of psychopathology during my intern year, yet one patient was uniquely memorable. When stable, he worked as a counselor, though for any number of reasons (eg, missing a dose of medication, smoking marijuana) his manic symptoms would emerge quickly, the disease rearing its ugly head within hours. He would become extremely hyperactive, elated, disinhibited (running naked in the streets), and grandiose (believing he was working for the president). He would be escorted to our psychiatric emergency department (ED) by police, who would have to resort to handcuffing him. His symptoms were described by ED and inpatient nursing staff and residents as “disorganized,” “psychotic,” “agitated,”’ or “combative.” He would receive large doses of intramuscular (IM) haloperidol, chlorpromazine, and diphenhydramine in desperate attempts to rein in his mania. Frustratingly—and paradoxically— this would make him more confused, disoriented, restless, and hyperactive, and often led to the need for restraints.

This behavior persisted for days until an attending I was working with assessed him. The attending observed that the patient did not know his current location, day of the week or month, or how he ended up in the hospital. He observed this patient intermittently staring, making abnormal repetitive movements with his arms and hands, occasionally freezing, making impulsive movements, and becoming combative without provocation. His heart rate and temperature were elevated; he was diaphoretic, especially after receiving parenteral antipsychotics. The attending, a pupil of Max Fink, made the diagnosis: delirious mania, a form of catatonia.^1,2 Resolution was quick and complete after 6 bilateral electroconvulsive therapy (ECT) sessions.

Catatonia, a neuropsychiatric phenomenon characterized by abnormal speech, movement, and affect, has undergone numerous paradigm shifts since it was recognized by Karl Ludwig Kahlbaum in 1874.³ Shortly after Kahlbaum, Emil Kraepelin held the belief that catatonia was a subtype of dementia praecox, or what is now known as schizophrenia.⁴ Due to this, patients were likely receiving less-than-optimal treatments, because their catatonia was being diagnosed as acute psychosis. Finally, in DSM-5, catatonia was unshackled from the constraints of schizophrenia and is now an entity of its own.⁵ However, catatonia is often met with incertitude (despite being present in up to 15% of inpatients),¹ with its treatment typically delayed or not even pursued. This is amplified because many forms of catatonia are often misdiagnosed as disorders that are more common or better understood.

Potential catatonia presentations

Delirious mania. Patients with delirious mania typically present with acute delirium, severe paranoia, hyperactivity, and visual/auditory hallucinations.^2,6,7 They usually have excited catatonic signs, such as excessive movement, combativeness, impulsivity, stereotypy, and echophenomena. Unfortunately, the catatonia is overshadowed by extreme psychotic and manic symptoms, or delirium (for which an underlying medical cause is usually not found). As was the case for the patient I described earlier, large doses of IM antipsychotics usually are administered, which can cause neuroleptic malignant syndrome (NMS) or precipitate seizures.⁸

Neuroleptic malignant syndrome. NMS is marked by fever, elevated blood pressure and heart rate, lead-pipe rigidity, parkinsonian features, altered mental status, and lab abnormalities (elevated liver enzymes or creatinine phosphokinase). This syndrome is preceded by the administration of an antipsychotic. It has features of catatonia that include mutism, negativism, and posturing.⁹ NMS is commonly interpreted as a subtype of malignant catatonia. Some argue that the diagnosis of malignant catatonia yields a more favorable outcome because it leads to more effective treatments (ie, benzodiazepines and ECT as opposed to dopamine agonists and dantrolene).¹⁰ Because NMS has much overlap with serotonin syndrome and drug-induced parkinsonism, initiation of benzodiazepines and ECT often is delayed.¹¹

Retarded catatonia. This version of catatonia usually is well recognized. The typical presentation is a patient who does not speak (mutism) or move (stupor), stares, becomes withdrawn (does not eat or drink), or maintains abnormal posturing. Retarded catatonia can be confused with a major depressive episode or hypoactive delirium.

Catatonia in autism spectrum disorder. Historically, co-occurring catatonia and autism spectrum disorder (ASD) was believed to be extremely rare. However, recent retrospective studies have found that up to 17% of patients with ASD older than age 15 have catatonia.¹² Many pediatric psychiatrists fail to recognize catatonia; in 1 study, only 2 patients (of 18) were correctly identified as having catatonia.¹³ The catatonic signs may vary, but the core features include withdrawal (children may need a feeding tube), decreased communication and/or worsening psychomotor slowing, agitation, or stereotypical movements, which can manifest as worsening self-injurious behavior.^14,15

An approach to treatment

Regardless of the etiology or presentation, first-line treatment for catatonia is benzodiazepines and/or ECT. A lorazepam challenge is used for diagnostic clarification; if effective, lorazepam can be titrated until symptoms fully resolve.^16,17 Doses >20 mg have been reported as effective and well-tolerated, without the feared sedation and respiratory depression.⁶ An unsuccessful lorazepam challenge does not rule out catatonia. If benzodiazepine therapy fails or the patient requires immediate symptom relief, ECT is the most effective treatment. Many clinicians use a bilateral electrode placement with high-energy dosing and frequent sessions until the catatonia resolves.^1,18

In my experience, catatonia in all its forms remains poorly recognized, with its treatment questioned. Residents—especially those in psychiatry—must understand that catatonia can result in systemic illness or death.

Direct immunofluorescence (DIF) is the go-to diagnostic test when evaluating vesiculobullous eruptions, connective tissue disease, and vasculitis. This specialized test allows visualization of autoantibodies and their reaction products in the epidermis and dermis (skin) and epithelium and subepithelium (mucosa). Indirect immunofluorescence (IIF) and enzyme-linked immunosorbent assay (ELISA) are additional tests that can help in the diagnosis of autoimmune blistering disease. In the blistering autoimmune diseases, the autoantibodies target components in skin and mucous membranes that are essential for cell-cell and cell-matrix adhesion causing separation within or beneath the epidermis, depending on where the target components are located. This article is intended to serve as a helpful primer for immunofluorescence testing in dermatology, with an overview of the tests available as well as pragmatic tips for optimal biopsy sites and specimen transport.

Direct Immunofluorescence

Immunofluorescence techniques date back to 1941 when Albert Coons, an American physician, pathologist, and immunologist, fluorescently labelled antibodies to visualize pneumococcal antigens in infected tissues.^1-3 In dermatology, similar methodology was used to visualize the deposition of immunoglobulins and complement in the skin of patients with systemic lupus erythematosus in 1963.⁴ Basement membrane zone antibodies were first visualized via DIF in bullous pemphigoid in 1967.⁵ This elegant test utilizes specific antibodies labeled with fluorophores that are then incubated with the patient’s tissue, ultimately forming antibody-antigen conjugates that can be visualized with a fluorescent microscope. Antibodies usually include IgG, IgM, IgA, fibrinogen, and C3. Some institutions also evaluate for IgG4.

Transport medium is critical for proper evaluation of tissues using DIF. Inappropriate storage of tissue can degrade the antigen and confuse the interpretation of specimens. An acceptable medium for DIF includes Michel transport medium, which allows tissue to be stored for days while being transported at ambient temperature without loss of signal.^6,7 Zeus medium also can be used and is more readily available. Alternatively, biopsy tissue can be snap frozen using liquid nitrogen. Specimens also may be stored on saline gauze but should be analyzed within 24 to 48 hours.⁸ Most importantly, do not place the specimen in formalin; even a brief soak in formalin can greatly alter results, especially when trying to diagnose pemphigus.⁹ Proper transport conditions are critical to prevent autolysis, mitigate putrefaction, and preserve morphology while maintaining antigenicity.¹⁰

Indirect Immunofluorescence

Indirect immunofluorescence can be helpful for detecting antibodies circulating in patient serum. Indirect immunofluorescence can be used to help diagnose pemphigoid, pemphigus, epidermolysis bullosa acquisita, bullous lupus erythematosus, and dermatitis herpetiformis. Serum testing also can be a helpful alternative when obtaining tissue is difficult, such as in children.

Indirect immunofluorescence is a 2-part technique that takes a bit longer to assay than DIF.¹¹ The first step involves incubating prepared tissue substrates with patient serum. Unlabeled antibodies in the patient serum are allowed to bind to antigens in the substrate tissue for about 30 minutes. Doubling dilutions of patient serum can be performed to titer antibody levels. The second step uses fluorescein-labeled antihuman antibodies to recognize the antigen-antibody conjugates. Normal whole tissues (eg, monkey esophagus for pemphigus vulgaris, rat bladder for paraneoplastic pemphigus, salt-split normal human skin substrate for pemphigoid and epidermolysis bullosa) are the usual substrates for testing.^11,12 Again, this test requires serum and should be collected in a red-top tube or serum-separator tube. Usually, a minimum of 0.5 mL is required for testing, but check with your preferred immunodermatology send-out laboratory before collecting.¹³

Indirect immunofluorescence usually involves an initial screening panel using 1 or 2 tissue substrates followed by individual antigen-specific assays that correspond to the clinical suspicion and IIF screening results.¹¹ Salt-split skin is used to localize basement membrane zone autoantibodies to either the epidermal (roof) or dermal (floor) side. Although many dermatopathology laboratories offer DIF testing, IIF is more specialized and may be a send-out test at your institution.

Enzyme-linked Immunosorbent Assays

Another tool in the immunodermatology armamentarium is ELISA. Commercial ELISA systems are available for the detection of autoantibodies against bullous pemphigoid (BP) antigen 180, BP230, type VII collagen, desmoglein (Dsg) 1, Dsg3, and envoplakin.¹¹ This test allows semiquantitative measurement of antibody levels and thus can be used to monitor response to treatment or identify relapse and treatment failure.¹¹ For example, in BP, significantly increased baseline anti-BP180 IgG levels correlate with 1-year mortality rates (P=.001) and relapse rates (P=.041).^14,15 Numerous additional studies support the observation that monitoring anti-BP180 as a potential marker of disease relapse can be helpful.^16,17 In pemphigus, the presence or increase of autoantibodies at remission, either anti-Dsg3 or anti-Dsg1, may be a useful tool in predicting disease relapse.¹⁸ It is important for physicians to be aware of this to be able to offer guidance on prognosis.

Knowing where to biopsy can be confusing when beginning residency. But the short answer is, it depends. Let your clinical suspicion guide your specimen site. The Figure provides a quick reference for which location will give you the highest yield for a specific diagnosis.

A few cardinal rules should guide which site is biopsied. Avoid obtaining specimens from the lower extremities as much as possible, as this site has been linked with false-negative results, especially in bullous pemphigoid.^19,20 As a dependent area prone to stasis, this site gets a lot of abuse and inflammatory changes secondary to everyday insults that can theoretically alter DIF findings, especially fibrinogen deposition.

Although tissue sent for hematoxylin and eosin staining should be lesional, biopsy for DIF ideally should not contain a new or active blister, ulcer, erosion, or bulla. Immunoreactants are more likely to be degraded in these areas, and DIF may be falsely negative.²¹

It is worthwhile to briefly discuss the definitions of the terms perilesional and nonlesional. Perilesional skin most frequently refers to skin adjacent to a bulla or vesicle. This skin can be erythematous/inflamed or appear normal. When obtaining tissue for a diagnosis of blistering disease, the general recommendation is to obtain the biopsy from lesional nonbullous skin or perilesional uninvolved skin within 1 cm of the bulla.^22-24 The only exception to this is dermatitis herpetiformis, which is best diagnosed on tissue obtained from normal-appearing perilesional skin within 1 cm of an active lesion.²⁵ Additionally, if your patient has oral disease, the recommendation is to obtain the biopsy from nonlesional buccal mucosa, especially if there is desquamative gingivitis.^26,27

The ideal biopsy size is 4 or 5 mm. If considering both DIF and histopathology, it is best to procure 2 separate specimens. One larger biopsy can be carefully bisected in 2 but often is subject to more handling artifacts, which can affect findings. In the case of 1 biopsy bisected into 2 specimens, the punch should be at least 6 mm. Shave biopsies also can be performed as long as they extend into the reticular dermis.²³

For vasculitis, biopsies for DIF should be taken from lesions that are less than 24 hours old for highest yield, as the level of tissue immunoreactants tends to decline over time.²⁸ This guideline does differ from hematoxylin and eosin specimens sent for evaluation of vasculitis, which ideally should be lesional tissue over 72 hours old. When evaluating for lupus (including subacute cutaneous lupus, discoid lupus, and systemic lupus), DIF is more likely to be positive in well-established, active lesions.

Which Test Should I Order?

The answer to this question depends, but the use of all 3 tests has a specificity close to 100% when evaluating for autoantibody-associated diseases.²³ For autoimmune blistering disease, DIF is considered the diagnostic standard. The sensitivity of DIF for diagnosing BP is in the range of 82% to 90.5%, while specificity is 98%.^29-31 Other autoimmune blistering diseases, such as pemphigus or dermatitis herpetiformis, have even higher sensitivities and specificities. Direct immunofluorescence often is used as a screening test, but false negatives do occur.^32,33 Although rare, false positives also can occur, especially in cases of infection, and should be suspected when there is a lack of clinicopathologic correlation.³⁴ If DIF is negative but clinical suspicion remains high, IIF should be ordered to directly evaluate a patient’s serum for autoantibodies.

In acute cutaneous lupus, subacute cutaneous lupus, and discoid lupus, DIF of active lesions may be helpful if histopathologic examination of a cutaneous lupus erythematosus lesion is nondiagnostic. However, histopathologic examination of formalin-fixed tissue remains the standard for these diagnoses. In vasculitis, while DIF is not used for diagnosis, it is useful to evaluate for IgA deposition. This is important in adults, as IgA deposition has been associated with a greater risk for developing end-stage renal disease.³⁵

Final Thoughts

This is an overview of the tests available for diagnosing autoimmune blistering diseases. Residents should keep in mind that these tests are just one part of the puzzle when it comes to diagnosing these diseases. Results of DIF, IIF, and ELISA testing should be considered in conjunction with patient history and physical examination as well as histopathologic examination of lesional tissue when evaluating for dermatologic diseases with autoantibodies.

Direct immunofluorescence (DIF) is the go-to diagnostic test when evaluating vesiculobullous eruptions, connective tissue disease, and vasculitis. This specialized test allows visualization of autoantibodies and their reaction products in the epidermis and dermis (skin) and epithelium and subepithelium (mucosa). Indirect immunofluorescence (IIF) and enzyme-linked immunosorbent assay (ELISA) are additional tests that can help in the diagnosis of autoimmune blistering disease. In the blistering autoimmune diseases, the autoantibodies target components in skin and mucous membranes that are essential for cell-cell and cell-matrix adhesion causing separation within or beneath the epidermis, depending on where the target components are located. This article is intended to serve as a helpful primer for immunofluorescence testing in dermatology, with an overview of the tests available as well as pragmatic tips for optimal biopsy sites and specimen transport.

Direct Immunofluorescence

Immunofluorescence techniques date back to 1941 when Albert Coons, an American physician, pathologist, and immunologist, fluorescently labelled antibodies to visualize pneumococcal antigens in infected tissues.^1-3 In dermatology, similar methodology was used to visualize the deposition of immunoglobulins and complement in the skin of patients with systemic lupus erythematosus in 1963.⁴ Basement membrane zone antibodies were first visualized via DIF in bullous pemphigoid in 1967.⁵ This elegant test utilizes specific antibodies labeled with fluorophores that are then incubated with the patient’s tissue, ultimately forming antibody-antigen conjugates that can be visualized with a fluorescent microscope. Antibodies usually include IgG, IgM, IgA, fibrinogen, and C3. Some institutions also evaluate for IgG4.

Transport medium is critical for proper evaluation of tissues using DIF. Inappropriate storage of tissue can degrade the antigen and confuse the interpretation of specimens. An acceptable medium for DIF includes Michel transport medium, which allows tissue to be stored for days while being transported at ambient temperature without loss of signal.^6,7 Zeus medium also can be used and is more readily available. Alternatively, biopsy tissue can be snap frozen using liquid nitrogen. Specimens also may be stored on saline gauze but should be analyzed within 24 to 48 hours.⁸ Most importantly, do not place the specimen in formalin; even a brief soak in formalin can greatly alter results, especially when trying to diagnose pemphigus.⁹ Proper transport conditions are critical to prevent autolysis, mitigate putrefaction, and preserve morphology while maintaining antigenicity.¹⁰

Indirect Immunofluorescence

Indirect immunofluorescence can be helpful for detecting antibodies circulating in patient serum. Indirect immunofluorescence can be used to help diagnose pemphigoid, pemphigus, epidermolysis bullosa acquisita, bullous lupus erythematosus, and dermatitis herpetiformis. Serum testing also can be a helpful alternative when obtaining tissue is difficult, such as in children.

Indirect immunofluorescence is a 2-part technique that takes a bit longer to assay than DIF.¹¹ The first step involves incubating prepared tissue substrates with patient serum. Unlabeled antibodies in the patient serum are allowed to bind to antigens in the substrate tissue for about 30 minutes. Doubling dilutions of patient serum can be performed to titer antibody levels. The second step uses fluorescein-labeled antihuman antibodies to recognize the antigen-antibody conjugates. Normal whole tissues (eg, monkey esophagus for pemphigus vulgaris, rat bladder for paraneoplastic pemphigus, salt-split normal human skin substrate for pemphigoid and epidermolysis bullosa) are the usual substrates for testing.^11,12 Again, this test requires serum and should be collected in a red-top tube or serum-separator tube. Usually, a minimum of 0.5 mL is required for testing, but check with your preferred immunodermatology send-out laboratory before collecting.¹³

Indirect immunofluorescence usually involves an initial screening panel using 1 or 2 tissue substrates followed by individual antigen-specific assays that correspond to the clinical suspicion and IIF screening results.¹¹ Salt-split skin is used to localize basement membrane zone autoantibodies to either the epidermal (roof) or dermal (floor) side. Although many dermatopathology laboratories offer DIF testing, IIF is more specialized and may be a send-out test at your institution.

Enzyme-linked Immunosorbent Assays

Another tool in the immunodermatology armamentarium is ELISA. Commercial ELISA systems are available for the detection of autoantibodies against bullous pemphigoid (BP) antigen 180, BP230, type VII collagen, desmoglein (Dsg) 1, Dsg3, and envoplakin.¹¹ This test allows semiquantitative measurement of antibody levels and thus can be used to monitor response to treatment or identify relapse and treatment failure.¹¹ For example, in BP, significantly increased baseline anti-BP180 IgG levels correlate with 1-year mortality rates (P=.001) and relapse rates (P=.041).^14,15 Numerous additional studies support the observation that monitoring anti-BP180 as a potential marker of disease relapse can be helpful.^16,17 In pemphigus, the presence or increase of autoantibodies at remission, either anti-Dsg3 or anti-Dsg1, may be a useful tool in predicting disease relapse.¹⁸ It is important for physicians to be aware of this to be able to offer guidance on prognosis.

Knowing where to biopsy can be confusing when beginning residency. But the short answer is, it depends. Let your clinical suspicion guide your specimen site. The Figure provides a quick reference for which location will give you the highest yield for a specific diagnosis.

A few cardinal rules should guide which site is biopsied. Avoid obtaining specimens from the lower extremities as much as possible, as this site has been linked with false-negative results, especially in bullous pemphigoid.^19,20 As a dependent area prone to stasis, this site gets a lot of abuse and inflammatory changes secondary to everyday insults that can theoretically alter DIF findings, especially fibrinogen deposition.

Although tissue sent for hematoxylin and eosin staining should be lesional, biopsy for DIF ideally should not contain a new or active blister, ulcer, erosion, or bulla. Immunoreactants are more likely to be degraded in these areas, and DIF may be falsely negative.²¹

It is worthwhile to briefly discuss the definitions of the terms perilesional and nonlesional. Perilesional skin most frequently refers to skin adjacent to a bulla or vesicle. This skin can be erythematous/inflamed or appear normal. When obtaining tissue for a diagnosis of blistering disease, the general recommendation is to obtain the biopsy from lesional nonbullous skin or perilesional uninvolved skin within 1 cm of the bulla.^22-24 The only exception to this is dermatitis herpetiformis, which is best diagnosed on tissue obtained from normal-appearing perilesional skin within 1 cm of an active lesion.²⁵ Additionally, if your patient has oral disease, the recommendation is to obtain the biopsy from nonlesional buccal mucosa, especially if there is desquamative gingivitis.^26,27

The ideal biopsy size is 4 or 5 mm. If considering both DIF and histopathology, it is best to procure 2 separate specimens. One larger biopsy can be carefully bisected in 2 but often is subject to more handling artifacts, which can affect findings. In the case of 1 biopsy bisected into 2 specimens, the punch should be at least 6 mm. Shave biopsies also can be performed as long as they extend into the reticular dermis.²³

For vasculitis, biopsies for DIF should be taken from lesions that are less than 24 hours old for highest yield, as the level of tissue immunoreactants tends to decline over time.²⁸ This guideline does differ from hematoxylin and eosin specimens sent for evaluation of vasculitis, which ideally should be lesional tissue over 72 hours old. When evaluating for lupus (including subacute cutaneous lupus, discoid lupus, and systemic lupus), DIF is more likely to be positive in well-established, active lesions.

Which Test Should I Order?

The answer to this question depends, but the use of all 3 tests has a specificity close to 100% when evaluating for autoantibody-associated diseases.²³ For autoimmune blistering disease, DIF is considered the diagnostic standard. The sensitivity of DIF for diagnosing BP is in the range of 82% to 90.5%, while specificity is 98%.^29-31 Other autoimmune blistering diseases, such as pemphigus or dermatitis herpetiformis, have even higher sensitivities and specificities. Direct immunofluorescence often is used as a screening test, but false negatives do occur.^32,33 Although rare, false positives also can occur, especially in cases of infection, and should be suspected when there is a lack of clinicopathologic correlation.³⁴ If DIF is negative but clinical suspicion remains high, IIF should be ordered to directly evaluate a patient’s serum for autoantibodies.

In acute cutaneous lupus, subacute cutaneous lupus, and discoid lupus, DIF of active lesions may be helpful if histopathologic examination of a cutaneous lupus erythematosus lesion is nondiagnostic. However, histopathologic examination of formalin-fixed tissue remains the standard for these diagnoses. In vasculitis, while DIF is not used for diagnosis, it is useful to evaluate for IgA deposition. This is important in adults, as IgA deposition has been associated with a greater risk for developing end-stage renal disease.³⁵

Final Thoughts

This is an overview of the tests available for diagnosing autoimmune blistering diseases. Residents should keep in mind that these tests are just one part of the puzzle when it comes to diagnosing these diseases. Results of DIF, IIF, and ELISA testing should be considered in conjunction with patient history and physical examination as well as histopathologic examination of lesional tissue when evaluating for dermatologic diseases with autoantibodies.

Direct immunofluorescence (DIF) is the go-to diagnostic test when evaluating vesiculobullous eruptions, connective tissue disease, and vasculitis. This specialized test allows visualization of autoantibodies and their reaction products in the epidermis and dermis (skin) and epithelium and subepithelium (mucosa). Indirect immunofluorescence (IIF) and enzyme-linked immunosorbent assay (ELISA) are additional tests that can help in the diagnosis of autoimmune blistering disease. In the blistering autoimmune diseases, the autoantibodies target components in skin and mucous membranes that are essential for cell-cell and cell-matrix adhesion causing separation within or beneath the epidermis, depending on where the target components are located. This article is intended to serve as a helpful primer for immunofluorescence testing in dermatology, with an overview of the tests available as well as pragmatic tips for optimal biopsy sites and specimen transport.

Direct Immunofluorescence

Immunofluorescence techniques date back to 1941 when Albert Coons, an American physician, pathologist, and immunologist, fluorescently labelled antibodies to visualize pneumococcal antigens in infected tissues.^1-3 In dermatology, similar methodology was used to visualize the deposition of immunoglobulins and complement in the skin of patients with systemic lupus erythematosus in 1963.⁴ Basement membrane zone antibodies were first visualized via DIF in bullous pemphigoid in 1967.⁵ This elegant test utilizes specific antibodies labeled with fluorophores that are then incubated with the patient’s tissue, ultimately forming antibody-antigen conjugates that can be visualized with a fluorescent microscope. Antibodies usually include IgG, IgM, IgA, fibrinogen, and C3. Some institutions also evaluate for IgG4.

Transport medium is critical for proper evaluation of tissues using DIF. Inappropriate storage of tissue can degrade the antigen and confuse the interpretation of specimens. An acceptable medium for DIF includes Michel transport medium, which allows tissue to be stored for days while being transported at ambient temperature without loss of signal.^6,7 Zeus medium also can be used and is more readily available. Alternatively, biopsy tissue can be snap frozen using liquid nitrogen. Specimens also may be stored on saline gauze but should be analyzed within 24 to 48 hours.⁸ Most importantly, do not place the specimen in formalin; even a brief soak in formalin can greatly alter results, especially when trying to diagnose pemphigus.⁹ Proper transport conditions are critical to prevent autolysis, mitigate putrefaction, and preserve morphology while maintaining antigenicity.¹⁰

Indirect Immunofluorescence

Indirect immunofluorescence can be helpful for detecting antibodies circulating in patient serum. Indirect immunofluorescence can be used to help diagnose pemphigoid, pemphigus, epidermolysis bullosa acquisita, bullous lupus erythematosus, and dermatitis herpetiformis. Serum testing also can be a helpful alternative when obtaining tissue is difficult, such as in children.

Indirect immunofluorescence is a 2-part technique that takes a bit longer to assay than DIF.¹¹ The first step involves incubating prepared tissue substrates with patient serum. Unlabeled antibodies in the patient serum are allowed to bind to antigens in the substrate tissue for about 30 minutes. Doubling dilutions of patient serum can be performed to titer antibody levels. The second step uses fluorescein-labeled antihuman antibodies to recognize the antigen-antibody conjugates. Normal whole tissues (eg, monkey esophagus for pemphigus vulgaris, rat bladder for paraneoplastic pemphigus, salt-split normal human skin substrate for pemphigoid and epidermolysis bullosa) are the usual substrates for testing.^11,12 Again, this test requires serum and should be collected in a red-top tube or serum-separator tube. Usually, a minimum of 0.5 mL is required for testing, but check with your preferred immunodermatology send-out laboratory before collecting.¹³

Indirect immunofluorescence usually involves an initial screening panel using 1 or 2 tissue substrates followed by individual antigen-specific assays that correspond to the clinical suspicion and IIF screening results.¹¹ Salt-split skin is used to localize basement membrane zone autoantibodies to either the epidermal (roof) or dermal (floor) side. Although many dermatopathology laboratories offer DIF testing, IIF is more specialized and may be a send-out test at your institution.

Enzyme-linked Immunosorbent Assays

Another tool in the immunodermatology armamentarium is ELISA. Commercial ELISA systems are available for the detection of autoantibodies against bullous pemphigoid (BP) antigen 180, BP230, type VII collagen, desmoglein (Dsg) 1, Dsg3, and envoplakin.¹¹ This test allows semiquantitative measurement of antibody levels and thus can be used to monitor response to treatment or identify relapse and treatment failure.¹¹ For example, in BP, significantly increased baseline anti-BP180 IgG levels correlate with 1-year mortality rates (P=.001) and relapse rates (P=.041).^14,15 Numerous additional studies support the observation that monitoring anti-BP180 as a potential marker of disease relapse can be helpful.^16,17 In pemphigus, the presence or increase of autoantibodies at remission, either anti-Dsg3 or anti-Dsg1, may be a useful tool in predicting disease relapse.¹⁸ It is important for physicians to be aware of this to be able to offer guidance on prognosis.

Knowing where to biopsy can be confusing when beginning residency. But the short answer is, it depends. Let your clinical suspicion guide your specimen site. The Figure provides a quick reference for which location will give you the highest yield for a specific diagnosis.

A few cardinal rules should guide which site is biopsied. Avoid obtaining specimens from the lower extremities as much as possible, as this site has been linked with false-negative results, especially in bullous pemphigoid.^19,20 As a dependent area prone to stasis, this site gets a lot of abuse and inflammatory changes secondary to everyday insults that can theoretically alter DIF findings, especially fibrinogen deposition.

Although tissue sent for hematoxylin and eosin staining should be lesional, biopsy for DIF ideally should not contain a new or active blister, ulcer, erosion, or bulla. Immunoreactants are more likely to be degraded in these areas, and DIF may be falsely negative.²¹

It is worthwhile to briefly discuss the definitions of the terms perilesional and nonlesional. Perilesional skin most frequently refers to skin adjacent to a bulla or vesicle. This skin can be erythematous/inflamed or appear normal. When obtaining tissue for a diagnosis of blistering disease, the general recommendation is to obtain the biopsy from lesional nonbullous skin or perilesional uninvolved skin within 1 cm of the bulla.^22-24 The only exception to this is dermatitis herpetiformis, which is best diagnosed on tissue obtained from normal-appearing perilesional skin within 1 cm of an active lesion.²⁵ Additionally, if your patient has oral disease, the recommendation is to obtain the biopsy from nonlesional buccal mucosa, especially if there is desquamative gingivitis.^26,27

The ideal biopsy size is 4 or 5 mm. If considering both DIF and histopathology, it is best to procure 2 separate specimens. One larger biopsy can be carefully bisected in 2 but often is subject to more handling artifacts, which can affect findings. In the case of 1 biopsy bisected into 2 specimens, the punch should be at least 6 mm. Shave biopsies also can be performed as long as they extend into the reticular dermis.²³

For vasculitis, biopsies for DIF should be taken from lesions that are less than 24 hours old for highest yield, as the level of tissue immunoreactants tends to decline over time.²⁸ This guideline does differ from hematoxylin and eosin specimens sent for evaluation of vasculitis, which ideally should be lesional tissue over 72 hours old. When evaluating for lupus (including subacute cutaneous lupus, discoid lupus, and systemic lupus), DIF is more likely to be positive in well-established, active lesions.

Which Test Should I Order?

The answer to this question depends, but the use of all 3 tests has a specificity close to 100% when evaluating for autoantibody-associated diseases.²³ For autoimmune blistering disease, DIF is considered the diagnostic standard. The sensitivity of DIF for diagnosing BP is in the range of 82% to 90.5%, while specificity is 98%.^29-31 Other autoimmune blistering diseases, such as pemphigus or dermatitis herpetiformis, have even higher sensitivities and specificities. Direct immunofluorescence often is used as a screening test, but false negatives do occur.^32,33 Although rare, false positives also can occur, especially in cases of infection, and should be suspected when there is a lack of clinicopathologic correlation.³⁴ If DIF is negative but clinical suspicion remains high, IIF should be ordered to directly evaluate a patient’s serum for autoantibodies.

In acute cutaneous lupus, subacute cutaneous lupus, and discoid lupus, DIF of active lesions may be helpful if histopathologic examination of a cutaneous lupus erythematosus lesion is nondiagnostic. However, histopathologic examination of formalin-fixed tissue remains the standard for these diagnoses. In vasculitis, while DIF is not used for diagnosis, it is useful to evaluate for IgA deposition. This is important in adults, as IgA deposition has been associated with a greater risk for developing end-stage renal disease.³⁵

Final Thoughts

This is an overview of the tests available for diagnosing autoimmune blistering diseases. Residents should keep in mind that these tests are just one part of the puzzle when it comes to diagnosing these diseases. Results of DIF, IIF, and ELISA testing should be considered in conjunction with patient history and physical examination as well as histopathologic examination of lesional tissue when evaluating for dermatologic diseases with autoantibodies.