For Residents

The adage “so much to do, so little time” aptly describes the daily challenges facing dermatologists and dermatology residents. The time and attention required by direct patient care, writing notes, navigating electronic health records, and engaging in education and research as well as family commitments can drain even the most tireless clinician. In addition, dermatologists are expected to play a critical role in clinic and practice management to successfully curate an online presence and adapt their skills to successfully manage a teledermatology practice. Coupled with the time spent socializing with friends or colleagues and time for personal hobbies or exercise, it’s easy to see how sleep deprivation is common in many of our colleagues.

What’s being left out of these jam-packed schedules? Increasingly, it is the time and expertise dedicated to volunteering in our local communities. Two recent research letters highlighted how a dramatic increase in the number of research projects and publications is not mirrored by a similar increase in volunteer experiences as dermatology residency selection becomes more competitive.^1,2

Although the rate of volunteerism among practicing dermatologists has yet to be studied, a brief review suggests a component of unmet dermatology need within our communities. It’s estimated that approximately 5% to 10% of all emergency department visits are for dermatologic concerns.^3-5 In many cases, the reason for the visit is nonurgent and instead reflects a lack of other options for care. However, the need for dermatologists extends beyond the emergency department setting. A review of the prevalence of patients presenting for care to a group of regional free clinics found that 8% (N=5553) of all visitors sought care for dermatologic concerns.⁶ The benefit is not just for those seated on the examination table; research has shown that while many of the underlying factors resulting in physician burnout stem from systemic issues, participating in volunteer opportunities helps combat burnout in ourselves and our colleagues.^7-9 Herein, opportunities that exist for dermatologists to reconnect with their communities, advocate for causes distinctive to the specialty, and care for neighbors most in need are highlighted.

Camp Wonder

Every year, children from across the United States living with chronic and debilitating skin conditions get the opportunity to join fellow campers and spend a week just being kids without the constant focus on being a patient. Camp Wonder’s founder and director, Francesca Tenconi, describes the camp as a place where kids “can form a community and can feel free to be themselves, without judgment, without stares. They get the chance to forget about their skin disease and be themselves” (oral communication, June 18, 2021). Tenconi and the camp’s cofounders and medical directors, Drs. Jenny Kim and Stefani Takahashi, envisioned the camp as a place for all campers regardless of their skin condition to feel safe and welcome. This overall mission guides camp leadership and staff every year over the course of the camp week where campers participate in a mix of traditional and nontraditional summer activities that are safe and accessible for all, from spending time in the pool to arts and crafts and a ropes course.

Camp Wonder is in its 21st year of hosting children and adolescents from across North America at its camp in Livermore, California. This year, Tenconi expects about 100 campers during the last week in July. Camp Wonder relies on medical staff volunteers to make the camp setting safe, inclusive, and fun. “Our dermatology residents and dermatology volunteers are a huge part of why we’re able to have camp,” said Tenconi. “A lot of our kids require very specific medical care throughout the week. We are able to provide this camp experience for them because we have this medical support system available, this specialized dermatology knowledge.” She also noted the benefit to the volunteers themselves, saying,“The feedback we get a lot from residents and dermatologists is that camp gave them a chance to understand the true-life impact of some of the skin diseases these kids and families are living with. Kids will open up to them and tell them how their disease has impacted them personally” (oral communication, June 18, 2021).

Volunteer medical providers help manage the medical needs of the campers beginning at check-in and work shifts in the infirmary as well as help with dispensing and administering medications, changing dressings, and applying ointments or other topical medications. When not assisting with medical care, medical staff can get to know the campers; help out with arts and crafts, games, sports, and other camp activities; and put on skits and plays for campers at nightly camp hangouts (Figure 1).

Native American Health Services Rotation

Located in the southwestern United States, the Navajo Nation is North America’s largest Native American tribe by enrollment and resides on the largest reservation in the United States.¹⁰ Comprised of 27,000 square miles within portions of Arizona, New Mexico, and Utah, the reservation’s total area is greater than that of Massachusetts, Vermont, and New Hampshire combined.¹¹ The reservation is home to an estimated 180,000 Navajo people, a population roughly the size of Salt Lake City, Utah. Yet, many homes on the reservation are without electricity, running water, telephones, or broadband access, and many roads on the reservation remain unpaved. Prior to the COVID-19 pandemic, 4 dermatology residents were selected each year to travel to this unique and remote location to work with the staff of the Chinle Comprehensive Health Care Facility (Chinle, Arizona), an Indian Health Service facility, as part of the American Academy of Dermatology (AAD)–sponsored Native American Health Services Resident Rotation (NAHSRR).

Dr. Lucinda Kohn, Assistant Professor of Dermatology at the University of Colorado and the director of the NAHSRR program discovered the value of this rotation firsthand as a dermatology resident. In 2017, she traveled to the area to spend 2 weeks serving within the community. “I went because of a personal connection. My husband is Native American, although not Navajo. I wanted to experience what it was like to provide dermatologic care for Native Americans. I found the Navajo people to be so friendly and so grateful for our care. The clinicians we worked with at Chinle were excited to have us share our expertise and to pass on their knowledge to us,” said Dr. Kohn (personal communication, June 24, 2021).

Rotating residents provide dermatologic care for the Navajo people and share their unique medical skill set to local primary care clinicians serving as preceptors. They also may have an opportunity to learn from Native healers about traditional Navajo beliefs and ceremonies used as part of a holistic approach to healing.

The program, similar to volunteer programs across the country, was put on hold during the height of the COVID-19 pandemic. “The Navajo nation witnessed a really tragic surge of COVID cases that required that limited medical resources be diverted to help cope with the pandemic,” says Dr. Kohn. “It really wasn’t safe for residents to travel to the reservation either, so the rotation had to be put on hold.” However, in April 2021, the health care staff of the Chinle Comprehensive Care Facility reached out to revive the program, which is now pending the green light from the AAD. It is unclear if or when AAD leadership will allow this rotation to restart. Dr. Kohn hopes to be able to start accepting new applications soon. “This rotation provides a wealth of benefits to all those involved, from the residents who get the chance to work with a unique population in need to the clinicians who gain a diverse understanding of dermatology treatment techniques. And of course, for the patients, who are so appreciative of the care they receive from our volunteers” (personal communication, June 25, 2021).

How to Get Involved
Dr. Kohn is happy to field questions regarding the rotation and requests for more information via email ([email protected]). Residents interested in this program also may reach out to the AAD’s Education and Volunteers Abroad Committee to express interest in the NAHSRR program’s reinstatement.

Destination Healthy Skin

Since 2017, the Skin Cancer Foundation’s Destination Healthy Skin (DHS) RV has been the setting for more than 3800 free skin cancer screenings provided by volunteers within underserved populations across the United States (Figure 2). After a year hiatus due to the pandemic, DHS hit the road again, starting in New York City on August 1 to 3, 2021. From there, the DHS RV will traverse the country in one large loop, starting with visits to large and small cities in the Midwest and the West Coast. Following a visit to San Diego, California, in early October, the RV will turn east, with stops in Arizona, Texas, and several southern states before ending in Philadelphia, Pennsylvania. Dr. Elizabeth Hale, Senior Vice President of the Skin Cancer Foundation, feels that increasing awareness of the importance of regular skin cancer screening for those at risk is more important than ever. “We know that many people in the past year put routine cancer screening on the back burner, but we’re beginning to appreciate that this has led to significant delays in skin cancer diagnosis and potentially more significant disease when cases are diagnosed.” Dr. Hale noted that as the country continues to return to a degree of normalcy, the backlog of patients now seeking their routine screening has led to longer wait times. She expects DHS may offer some relief. “There are no appointments necessary. If the RV is close to their hometown, patients have an advantage in being able to be seen first come, first served, without having to wait for an appointment or make sure their insurance is accepted. It’s a free screening that can increase access to dermatologists” (personal communication, June 21, 2021).

The program’s organizers acknowledge that DHS is not a long-term solution for improving dermatology access in the United States and recognize that more needs to be done to raise awareness, both of the value that screenings can provide and the importance of sun-protective behavior. “This is an important first step,” says Dr. Hale. “It’s important that we disseminate that no one is immune to skin cancer. It’s about education, and this is a tool to educate patients that everyone should have a skin check once a year, regardless of where you live or what your skin type is” (personal communication, June 21, 2021).

Volunteer dermatologists are needed to assist with screenings when the DHS RV arrives in their community. Providers complete a screening form identifying any concerning lesions and can document specific lesions using the patient’s cell phone. Following the screenings, participating dermatologists are welcome to invite participants to make appointments at their practices or suggest local clinics for follow-up care.

How to Get Involved
The schedule for this year’s screening events can be found online (https://www.skincancer.org/early-detection/destination-healthy-skin/). Consider volunteering (https://www.skincancer.org/early-detection/destination-healthy-skin/physician-volunteers/) or helping to raise awareness by reaching out to local dermatology societies or free clinics in your area. Residents and physician’s assistants are welcome to volunteer as well, as long as they are under the on-site supervision of a board-certified dermatologist.

Final Thoughts

As medical professionals, we all recognize there are valuable contributions we can make to groups and organizations that need our help. The stresses and pressure of work and everyday life can make finding the time to offer that help seem impossible. Although it may seem counterintuitive, volunteering our time to help others can help us better navigate the professional burnout that many medical professionals experience today.

The adage “so much to do, so little time” aptly describes the daily challenges facing dermatologists and dermatology residents. The time and attention required by direct patient care, writing notes, navigating electronic health records, and engaging in education and research as well as family commitments can drain even the most tireless clinician. In addition, dermatologists are expected to play a critical role in clinic and practice management to successfully curate an online presence and adapt their skills to successfully manage a teledermatology practice. Coupled with the time spent socializing with friends or colleagues and time for personal hobbies or exercise, it’s easy to see how sleep deprivation is common in many of our colleagues.

What’s being left out of these jam-packed schedules? Increasingly, it is the time and expertise dedicated to volunteering in our local communities. Two recent research letters highlighted how a dramatic increase in the number of research projects and publications is not mirrored by a similar increase in volunteer experiences as dermatology residency selection becomes more competitive.^1,2

Although the rate of volunteerism among practicing dermatologists has yet to be studied, a brief review suggests a component of unmet dermatology need within our communities. It’s estimated that approximately 5% to 10% of all emergency department visits are for dermatologic concerns.^3-5 In many cases, the reason for the visit is nonurgent and instead reflects a lack of other options for care. However, the need for dermatologists extends beyond the emergency department setting. A review of the prevalence of patients presenting for care to a group of regional free clinics found that 8% (N=5553) of all visitors sought care for dermatologic concerns.⁶ The benefit is not just for those seated on the examination table; research has shown that while many of the underlying factors resulting in physician burnout stem from systemic issues, participating in volunteer opportunities helps combat burnout in ourselves and our colleagues.^7-9 Herein, opportunities that exist for dermatologists to reconnect with their communities, advocate for causes distinctive to the specialty, and care for neighbors most in need are highlighted.

Camp Wonder

Every year, children from across the United States living with chronic and debilitating skin conditions get the opportunity to join fellow campers and spend a week just being kids without the constant focus on being a patient. Camp Wonder’s founder and director, Francesca Tenconi, describes the camp as a place where kids “can form a community and can feel free to be themselves, without judgment, without stares. They get the chance to forget about their skin disease and be themselves” (oral communication, June 18, 2021). Tenconi and the camp’s cofounders and medical directors, Drs. Jenny Kim and Stefani Takahashi, envisioned the camp as a place for all campers regardless of their skin condition to feel safe and welcome. This overall mission guides camp leadership and staff every year over the course of the camp week where campers participate in a mix of traditional and nontraditional summer activities that are safe and accessible for all, from spending time in the pool to arts and crafts and a ropes course.

Camp Wonder is in its 21st year of hosting children and adolescents from across North America at its camp in Livermore, California. This year, Tenconi expects about 100 campers during the last week in July. Camp Wonder relies on medical staff volunteers to make the camp setting safe, inclusive, and fun. “Our dermatology residents and dermatology volunteers are a huge part of why we’re able to have camp,” said Tenconi. “A lot of our kids require very specific medical care throughout the week. We are able to provide this camp experience for them because we have this medical support system available, this specialized dermatology knowledge.” She also noted the benefit to the volunteers themselves, saying,“The feedback we get a lot from residents and dermatologists is that camp gave them a chance to understand the true-life impact of some of the skin diseases these kids and families are living with. Kids will open up to them and tell them how their disease has impacted them personally” (oral communication, June 18, 2021).

Volunteer medical providers help manage the medical needs of the campers beginning at check-in and work shifts in the infirmary as well as help with dispensing and administering medications, changing dressings, and applying ointments or other topical medications. When not assisting with medical care, medical staff can get to know the campers; help out with arts and crafts, games, sports, and other camp activities; and put on skits and plays for campers at nightly camp hangouts (Figure 1).

Native American Health Services Rotation

Located in the southwestern United States, the Navajo Nation is North America’s largest Native American tribe by enrollment and resides on the largest reservation in the United States.¹⁰ Comprised of 27,000 square miles within portions of Arizona, New Mexico, and Utah, the reservation’s total area is greater than that of Massachusetts, Vermont, and New Hampshire combined.¹¹ The reservation is home to an estimated 180,000 Navajo people, a population roughly the size of Salt Lake City, Utah. Yet, many homes on the reservation are without electricity, running water, telephones, or broadband access, and many roads on the reservation remain unpaved. Prior to the COVID-19 pandemic, 4 dermatology residents were selected each year to travel to this unique and remote location to work with the staff of the Chinle Comprehensive Health Care Facility (Chinle, Arizona), an Indian Health Service facility, as part of the American Academy of Dermatology (AAD)–sponsored Native American Health Services Resident Rotation (NAHSRR).

Dr. Lucinda Kohn, Assistant Professor of Dermatology at the University of Colorado and the director of the NAHSRR program discovered the value of this rotation firsthand as a dermatology resident. In 2017, she traveled to the area to spend 2 weeks serving within the community. “I went because of a personal connection. My husband is Native American, although not Navajo. I wanted to experience what it was like to provide dermatologic care for Native Americans. I found the Navajo people to be so friendly and so grateful for our care. The clinicians we worked with at Chinle were excited to have us share our expertise and to pass on their knowledge to us,” said Dr. Kohn (personal communication, June 24, 2021).

Rotating residents provide dermatologic care for the Navajo people and share their unique medical skill set to local primary care clinicians serving as preceptors. They also may have an opportunity to learn from Native healers about traditional Navajo beliefs and ceremonies used as part of a holistic approach to healing.

The program, similar to volunteer programs across the country, was put on hold during the height of the COVID-19 pandemic. “The Navajo nation witnessed a really tragic surge of COVID cases that required that limited medical resources be diverted to help cope with the pandemic,” says Dr. Kohn. “It really wasn’t safe for residents to travel to the reservation either, so the rotation had to be put on hold.” However, in April 2021, the health care staff of the Chinle Comprehensive Care Facility reached out to revive the program, which is now pending the green light from the AAD. It is unclear if or when AAD leadership will allow this rotation to restart. Dr. Kohn hopes to be able to start accepting new applications soon. “This rotation provides a wealth of benefits to all those involved, from the residents who get the chance to work with a unique population in need to the clinicians who gain a diverse understanding of dermatology treatment techniques. And of course, for the patients, who are so appreciative of the care they receive from our volunteers” (personal communication, June 25, 2021).

How to Get Involved
Dr. Kohn is happy to field questions regarding the rotation and requests for more information via email ([email protected]). Residents interested in this program also may reach out to the AAD’s Education and Volunteers Abroad Committee to express interest in the NAHSRR program’s reinstatement.

Destination Healthy Skin

Since 2017, the Skin Cancer Foundation’s Destination Healthy Skin (DHS) RV has been the setting for more than 3800 free skin cancer screenings provided by volunteers within underserved populations across the United States (Figure 2). After a year hiatus due to the pandemic, DHS hit the road again, starting in New York City on August 1 to 3, 2021. From there, the DHS RV will traverse the country in one large loop, starting with visits to large and small cities in the Midwest and the West Coast. Following a visit to San Diego, California, in early October, the RV will turn east, with stops in Arizona, Texas, and several southern states before ending in Philadelphia, Pennsylvania. Dr. Elizabeth Hale, Senior Vice President of the Skin Cancer Foundation, feels that increasing awareness of the importance of regular skin cancer screening for those at risk is more important than ever. “We know that many people in the past year put routine cancer screening on the back burner, but we’re beginning to appreciate that this has led to significant delays in skin cancer diagnosis and potentially more significant disease when cases are diagnosed.” Dr. Hale noted that as the country continues to return to a degree of normalcy, the backlog of patients now seeking their routine screening has led to longer wait times. She expects DHS may offer some relief. “There are no appointments necessary. If the RV is close to their hometown, patients have an advantage in being able to be seen first come, first served, without having to wait for an appointment or make sure their insurance is accepted. It’s a free screening that can increase access to dermatologists” (personal communication, June 21, 2021).

The program’s organizers acknowledge that DHS is not a long-term solution for improving dermatology access in the United States and recognize that more needs to be done to raise awareness, both of the value that screenings can provide and the importance of sun-protective behavior. “This is an important first step,” says Dr. Hale. “It’s important that we disseminate that no one is immune to skin cancer. It’s about education, and this is a tool to educate patients that everyone should have a skin check once a year, regardless of where you live or what your skin type is” (personal communication, June 21, 2021).

Volunteer dermatologists are needed to assist with screenings when the DHS RV arrives in their community. Providers complete a screening form identifying any concerning lesions and can document specific lesions using the patient’s cell phone. Following the screenings, participating dermatologists are welcome to invite participants to make appointments at their practices or suggest local clinics for follow-up care.

How to Get Involved
The schedule for this year’s screening events can be found online (https://www.skincancer.org/early-detection/destination-healthy-skin/). Consider volunteering (https://www.skincancer.org/early-detection/destination-healthy-skin/physician-volunteers/) or helping to raise awareness by reaching out to local dermatology societies or free clinics in your area. Residents and physician’s assistants are welcome to volunteer as well, as long as they are under the on-site supervision of a board-certified dermatologist.

Final Thoughts

As medical professionals, we all recognize there are valuable contributions we can make to groups and organizations that need our help. The stresses and pressure of work and everyday life can make finding the time to offer that help seem impossible. Although it may seem counterintuitive, volunteering our time to help others can help us better navigate the professional burnout that many medical professionals experience today.

The adage “so much to do, so little time” aptly describes the daily challenges facing dermatologists and dermatology residents. The time and attention required by direct patient care, writing notes, navigating electronic health records, and engaging in education and research as well as family commitments can drain even the most tireless clinician. In addition, dermatologists are expected to play a critical role in clinic and practice management to successfully curate an online presence and adapt their skills to successfully manage a teledermatology practice. Coupled with the time spent socializing with friends or colleagues and time for personal hobbies or exercise, it’s easy to see how sleep deprivation is common in many of our colleagues.

What’s being left out of these jam-packed schedules? Increasingly, it is the time and expertise dedicated to volunteering in our local communities. Two recent research letters highlighted how a dramatic increase in the number of research projects and publications is not mirrored by a similar increase in volunteer experiences as dermatology residency selection becomes more competitive.^1,2

Although the rate of volunteerism among practicing dermatologists has yet to be studied, a brief review suggests a component of unmet dermatology need within our communities. It’s estimated that approximately 5% to 10% of all emergency department visits are for dermatologic concerns.^3-5 In many cases, the reason for the visit is nonurgent and instead reflects a lack of other options for care. However, the need for dermatologists extends beyond the emergency department setting. A review of the prevalence of patients presenting for care to a group of regional free clinics found that 8% (N=5553) of all visitors sought care for dermatologic concerns.⁶ The benefit is not just for those seated on the examination table; research has shown that while many of the underlying factors resulting in physician burnout stem from systemic issues, participating in volunteer opportunities helps combat burnout in ourselves and our colleagues.^7-9 Herein, opportunities that exist for dermatologists to reconnect with their communities, advocate for causes distinctive to the specialty, and care for neighbors most in need are highlighted.

Camp Wonder

Every year, children from across the United States living with chronic and debilitating skin conditions get the opportunity to join fellow campers and spend a week just being kids without the constant focus on being a patient. Camp Wonder’s founder and director, Francesca Tenconi, describes the camp as a place where kids “can form a community and can feel free to be themselves, without judgment, without stares. They get the chance to forget about their skin disease and be themselves” (oral communication, June 18, 2021). Tenconi and the camp’s cofounders and medical directors, Drs. Jenny Kim and Stefani Takahashi, envisioned the camp as a place for all campers regardless of their skin condition to feel safe and welcome. This overall mission guides camp leadership and staff every year over the course of the camp week where campers participate in a mix of traditional and nontraditional summer activities that are safe and accessible for all, from spending time in the pool to arts and crafts and a ropes course.

Camp Wonder is in its 21st year of hosting children and adolescents from across North America at its camp in Livermore, California. This year, Tenconi expects about 100 campers during the last week in July. Camp Wonder relies on medical staff volunteers to make the camp setting safe, inclusive, and fun. “Our dermatology residents and dermatology volunteers are a huge part of why we’re able to have camp,” said Tenconi. “A lot of our kids require very specific medical care throughout the week. We are able to provide this camp experience for them because we have this medical support system available, this specialized dermatology knowledge.” She also noted the benefit to the volunteers themselves, saying,“The feedback we get a lot from residents and dermatologists is that camp gave them a chance to understand the true-life impact of some of the skin diseases these kids and families are living with. Kids will open up to them and tell them how their disease has impacted them personally” (oral communication, June 18, 2021).

Volunteer medical providers help manage the medical needs of the campers beginning at check-in and work shifts in the infirmary as well as help with dispensing and administering medications, changing dressings, and applying ointments or other topical medications. When not assisting with medical care, medical staff can get to know the campers; help out with arts and crafts, games, sports, and other camp activities; and put on skits and plays for campers at nightly camp hangouts (Figure 1).

Native American Health Services Rotation

Located in the southwestern United States, the Navajo Nation is North America’s largest Native American tribe by enrollment and resides on the largest reservation in the United States.¹⁰ Comprised of 27,000 square miles within portions of Arizona, New Mexico, and Utah, the reservation’s total area is greater than that of Massachusetts, Vermont, and New Hampshire combined.¹¹ The reservation is home to an estimated 180,000 Navajo people, a population roughly the size of Salt Lake City, Utah. Yet, many homes on the reservation are without electricity, running water, telephones, or broadband access, and many roads on the reservation remain unpaved. Prior to the COVID-19 pandemic, 4 dermatology residents were selected each year to travel to this unique and remote location to work with the staff of the Chinle Comprehensive Health Care Facility (Chinle, Arizona), an Indian Health Service facility, as part of the American Academy of Dermatology (AAD)–sponsored Native American Health Services Resident Rotation (NAHSRR).

Dr. Lucinda Kohn, Assistant Professor of Dermatology at the University of Colorado and the director of the NAHSRR program discovered the value of this rotation firsthand as a dermatology resident. In 2017, she traveled to the area to spend 2 weeks serving within the community. “I went because of a personal connection. My husband is Native American, although not Navajo. I wanted to experience what it was like to provide dermatologic care for Native Americans. I found the Navajo people to be so friendly and so grateful for our care. The clinicians we worked with at Chinle were excited to have us share our expertise and to pass on their knowledge to us,” said Dr. Kohn (personal communication, June 24, 2021).

Rotating residents provide dermatologic care for the Navajo people and share their unique medical skill set to local primary care clinicians serving as preceptors. They also may have an opportunity to learn from Native healers about traditional Navajo beliefs and ceremonies used as part of a holistic approach to healing.

The program, similar to volunteer programs across the country, was put on hold during the height of the COVID-19 pandemic. “The Navajo nation witnessed a really tragic surge of COVID cases that required that limited medical resources be diverted to help cope with the pandemic,” says Dr. Kohn. “It really wasn’t safe for residents to travel to the reservation either, so the rotation had to be put on hold.” However, in April 2021, the health care staff of the Chinle Comprehensive Care Facility reached out to revive the program, which is now pending the green light from the AAD. It is unclear if or when AAD leadership will allow this rotation to restart. Dr. Kohn hopes to be able to start accepting new applications soon. “This rotation provides a wealth of benefits to all those involved, from the residents who get the chance to work with a unique population in need to the clinicians who gain a diverse understanding of dermatology treatment techniques. And of course, for the patients, who are so appreciative of the care they receive from our volunteers” (personal communication, June 25, 2021).

How to Get Involved
Dr. Kohn is happy to field questions regarding the rotation and requests for more information via email ([email protected]). Residents interested in this program also may reach out to the AAD’s Education and Volunteers Abroad Committee to express interest in the NAHSRR program’s reinstatement.

Destination Healthy Skin

Since 2017, the Skin Cancer Foundation’s Destination Healthy Skin (DHS) RV has been the setting for more than 3800 free skin cancer screenings provided by volunteers within underserved populations across the United States (Figure 2). After a year hiatus due to the pandemic, DHS hit the road again, starting in New York City on August 1 to 3, 2021. From there, the DHS RV will traverse the country in one large loop, starting with visits to large and small cities in the Midwest and the West Coast. Following a visit to San Diego, California, in early October, the RV will turn east, with stops in Arizona, Texas, and several southern states before ending in Philadelphia, Pennsylvania. Dr. Elizabeth Hale, Senior Vice President of the Skin Cancer Foundation, feels that increasing awareness of the importance of regular skin cancer screening for those at risk is more important than ever. “We know that many people in the past year put routine cancer screening on the back burner, but we’re beginning to appreciate that this has led to significant delays in skin cancer diagnosis and potentially more significant disease when cases are diagnosed.” Dr. Hale noted that as the country continues to return to a degree of normalcy, the backlog of patients now seeking their routine screening has led to longer wait times. She expects DHS may offer some relief. “There are no appointments necessary. If the RV is close to their hometown, patients have an advantage in being able to be seen first come, first served, without having to wait for an appointment or make sure their insurance is accepted. It’s a free screening that can increase access to dermatologists” (personal communication, June 21, 2021).

The program’s organizers acknowledge that DHS is not a long-term solution for improving dermatology access in the United States and recognize that more needs to be done to raise awareness, both of the value that screenings can provide and the importance of sun-protective behavior. “This is an important first step,” says Dr. Hale. “It’s important that we disseminate that no one is immune to skin cancer. It’s about education, and this is a tool to educate patients that everyone should have a skin check once a year, regardless of where you live or what your skin type is” (personal communication, June 21, 2021).

Volunteer dermatologists are needed to assist with screenings when the DHS RV arrives in their community. Providers complete a screening form identifying any concerning lesions and can document specific lesions using the patient’s cell phone. Following the screenings, participating dermatologists are welcome to invite participants to make appointments at their practices or suggest local clinics for follow-up care.

How to Get Involved
The schedule for this year’s screening events can be found online (https://www.skincancer.org/early-detection/destination-healthy-skin/). Consider volunteering (https://www.skincancer.org/early-detection/destination-healthy-skin/physician-volunteers/) or helping to raise awareness by reaching out to local dermatology societies or free clinics in your area. Residents and physician’s assistants are welcome to volunteer as well, as long as they are under the on-site supervision of a board-certified dermatologist.

Final Thoughts

As medical professionals, we all recognize there are valuable contributions we can make to groups and organizations that need our help. The stresses and pressure of work and everyday life can make finding the time to offer that help seem impossible. Although it may seem counterintuitive, volunteering our time to help others can help us better navigate the professional burnout that many medical professionals experience today.

In the modern-day practice of medicine, turf wars are more common than one may realize. Presently, an ongoing battle over who should be prescribing and administering ketamine for novel treatment uses is being waged among psychiatrists, anesthesiologists, family physicians, and emergency physicians. Whoever emerges victorious will determine whether psychiatric care is administered in a safe and cost-effective manner, or if it will merely benefit the bottom line of the prescriber. In this article, we discuss how ketamine may have a role for treatment-resistant depression (TRD), and why psychiatrists are uniquely qualified to prescribe and administer this medication for this purpose.

New approaches to treatment-resistant depression

Antidepressant medications, long the mainstay of depression treatment, have been shown to be safe and relatively equally effective, with varying tolerability. However, 33% percent of patients do not achieve remission after 4 trials of antidepressant therapy.¹ Most antidepressant efficacy studies report remission rates of 35% to 40%,² which means many patients require subsequent switching and/or augmentation of their treatment.³ The STAR*D trial demonstrated that after 2 adequate antidepressant trials, the likelihood of remission diminishes.⁴

After a patient’s depression is found to be treatment-resistant, the onus of guiding treatment shifts away from the patient’s primary care physician to the more specialized psychiatrist. Few would question the suitability of a psychiatrist’s expertise in handling complicated and nuanced mental illness. In order to manage TRD, psychiatrists enter a terrain of emerging novel therapies with rapid onset, different mechanisms of action, and parenteral routes of administration.

One such therapy is esketamine, the S-enantiomer of ketamine. The FDA approved the intranasal (IN) formulation of esketamine in March 2019 after the medication had been designated as a breakthrough therapy for TRD in 2013 and studied in 6 Phase III clinical trials.⁵ The S-enantiomer of ketamine is known to bind to the N-methyl-D-aspartate receptor stronger than the R-enantiomer.⁶ The mechanism of action of both stereoisomers on other receptors, such as opioid and alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA), is the focus of intensive research and remains to be fully elucidated, but initial studies indicate rapid neuroplasticity and synaptogenesis.⁷ What is clear is that this new intervention can provide relief to patients with TRD via a pharmacologically distinct mechanism.⁸

Ketamine may be administered intranasally, intravenously, or orally. A meta-analysis aimed at assessing differences in ketamine efficacy for depression based on route of administration have shown that both IV and IN ketamine are effective, though it is not possible to draw conclusions regarding a direct comparison based on available data.⁹ Despite several landmark published studies, such as those by Zarate et al,¹⁰ IV ketamine is not FDA-approved for TRD.

Continue to: Why psychiatrists?

Psychiatrists have been prescribing IN esketamine, which is covered by most commercial insurances and administered in certified healthcare settings under a Risk Evaluation and Mitigation Strategy program.⁵ However, anesthesiologists and emergency physicians have opened a crop of boutique and concierge health clinics offering various “packages” of IV ketamine infusions for a slew of mental ailments, including depression, anxiety, bipolar disorder, and posttraumatic stress disorder.¹¹ Minimal investigation reveals that these services are being prescribed mainly by practitioners in fields other than psychiatry. Intravenous ketamine has long been used off-label as a treatment for depression not by psychiatrists but by practitioners of anesthesiology or emergency medicine. Although these clinicians are likely familiar with ketamine as an anesthetic, they have no foundation or expertise in the diagnosis and treatment of complex mood disorders. The FDA-approved indication for esketamine falls firmly in the realm of psychiatric treatment. Physicians who have not completed a psychiatry residency have neither the training nor experience necessary to determine whether a patient is a candidate for this treatment.

One potential adverse effect of ketamine is an emergence phenomenon, colloquially named a “K-hole,” that can induce symptoms of psychosis such as disturbing hallucinations. Patients who have a history of psychosis need to be carefully evaluated for appropriateness to receive this treatment.

Furthermore, ketamine treatments administered by physicians who are not psychiatrists are billed not through insurance but mostly via private pay. A patient may therefore be charged $350 to $1,000 per infusion, to be paid out of pocket.¹¹ Tally that up over the standard 6 to 12 initial treatment infusions, followed by maintenance infusions, and these patients with profound depression are potentially building up significant debt. Does this practice align with the ethical principles of autonomy, justice, beneficence, and nonmaleficence that all physicians swore to uphold? Will psychiatrists take a stand against the financial exploitation of a vulnerable group that is desperate to find any potential relief from their depression?

In the modern-day practice of medicine, turf wars are more common than one may realize. Presently, an ongoing battle over who should be prescribing and administering ketamine for novel treatment uses is being waged among psychiatrists, anesthesiologists, family physicians, and emergency physicians. Whoever emerges victorious will determine whether psychiatric care is administered in a safe and cost-effective manner, or if it will merely benefit the bottom line of the prescriber. In this article, we discuss how ketamine may have a role for treatment-resistant depression (TRD), and why psychiatrists are uniquely qualified to prescribe and administer this medication for this purpose.

New approaches to treatment-resistant depression

Antidepressant medications, long the mainstay of depression treatment, have been shown to be safe and relatively equally effective, with varying tolerability. However, 33% percent of patients do not achieve remission after 4 trials of antidepressant therapy.¹ Most antidepressant efficacy studies report remission rates of 35% to 40%,² which means many patients require subsequent switching and/or augmentation of their treatment.³ The STAR*D trial demonstrated that after 2 adequate antidepressant trials, the likelihood of remission diminishes.⁴

After a patient’s depression is found to be treatment-resistant, the onus of guiding treatment shifts away from the patient’s primary care physician to the more specialized psychiatrist. Few would question the suitability of a psychiatrist’s expertise in handling complicated and nuanced mental illness. In order to manage TRD, psychiatrists enter a terrain of emerging novel therapies with rapid onset, different mechanisms of action, and parenteral routes of administration.

One such therapy is esketamine, the S-enantiomer of ketamine. The FDA approved the intranasal (IN) formulation of esketamine in March 2019 after the medication had been designated as a breakthrough therapy for TRD in 2013 and studied in 6 Phase III clinical trials.⁵ The S-enantiomer of ketamine is known to bind to the N-methyl-D-aspartate receptor stronger than the R-enantiomer.⁶ The mechanism of action of both stereoisomers on other receptors, such as opioid and alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA), is the focus of intensive research and remains to be fully elucidated, but initial studies indicate rapid neuroplasticity and synaptogenesis.⁷ What is clear is that this new intervention can provide relief to patients with TRD via a pharmacologically distinct mechanism.⁸

Ketamine may be administered intranasally, intravenously, or orally. A meta-analysis aimed at assessing differences in ketamine efficacy for depression based on route of administration have shown that both IV and IN ketamine are effective, though it is not possible to draw conclusions regarding a direct comparison based on available data.⁹ Despite several landmark published studies, such as those by Zarate et al,¹⁰ IV ketamine is not FDA-approved for TRD.

Continue to: Why psychiatrists?

Psychiatrists have been prescribing IN esketamine, which is covered by most commercial insurances and administered in certified healthcare settings under a Risk Evaluation and Mitigation Strategy program.⁵ However, anesthesiologists and emergency physicians have opened a crop of boutique and concierge health clinics offering various “packages” of IV ketamine infusions for a slew of mental ailments, including depression, anxiety, bipolar disorder, and posttraumatic stress disorder.¹¹ Minimal investigation reveals that these services are being prescribed mainly by practitioners in fields other than psychiatry. Intravenous ketamine has long been used off-label as a treatment for depression not by psychiatrists but by practitioners of anesthesiology or emergency medicine. Although these clinicians are likely familiar with ketamine as an anesthetic, they have no foundation or expertise in the diagnosis and treatment of complex mood disorders. The FDA-approved indication for esketamine falls firmly in the realm of psychiatric treatment. Physicians who have not completed a psychiatry residency have neither the training nor experience necessary to determine whether a patient is a candidate for this treatment.

One potential adverse effect of ketamine is an emergence phenomenon, colloquially named a “K-hole,” that can induce symptoms of psychosis such as disturbing hallucinations. Patients who have a history of psychosis need to be carefully evaluated for appropriateness to receive this treatment.

Furthermore, ketamine treatments administered by physicians who are not psychiatrists are billed not through insurance but mostly via private pay. A patient may therefore be charged $350 to $1,000 per infusion, to be paid out of pocket.¹¹ Tally that up over the standard 6 to 12 initial treatment infusions, followed by maintenance infusions, and these patients with profound depression are potentially building up significant debt. Does this practice align with the ethical principles of autonomy, justice, beneficence, and nonmaleficence that all physicians swore to uphold? Will psychiatrists take a stand against the financial exploitation of a vulnerable group that is desperate to find any potential relief from their depression?

In the modern-day practice of medicine, turf wars are more common than one may realize. Presently, an ongoing battle over who should be prescribing and administering ketamine for novel treatment uses is being waged among psychiatrists, anesthesiologists, family physicians, and emergency physicians. Whoever emerges victorious will determine whether psychiatric care is administered in a safe and cost-effective manner, or if it will merely benefit the bottom line of the prescriber. In this article, we discuss how ketamine may have a role for treatment-resistant depression (TRD), and why psychiatrists are uniquely qualified to prescribe and administer this medication for this purpose.

New approaches to treatment-resistant depression

Antidepressant medications, long the mainstay of depression treatment, have been shown to be safe and relatively equally effective, with varying tolerability. However, 33% percent of patients do not achieve remission after 4 trials of antidepressant therapy.¹ Most antidepressant efficacy studies report remission rates of 35% to 40%,² which means many patients require subsequent switching and/or augmentation of their treatment.³ The STAR*D trial demonstrated that after 2 adequate antidepressant trials, the likelihood of remission diminishes.⁴

After a patient’s depression is found to be treatment-resistant, the onus of guiding treatment shifts away from the patient’s primary care physician to the more specialized psychiatrist. Few would question the suitability of a psychiatrist’s expertise in handling complicated and nuanced mental illness. In order to manage TRD, psychiatrists enter a terrain of emerging novel therapies with rapid onset, different mechanisms of action, and parenteral routes of administration.

One such therapy is esketamine, the S-enantiomer of ketamine. The FDA approved the intranasal (IN) formulation of esketamine in March 2019 after the medication had been designated as a breakthrough therapy for TRD in 2013 and studied in 6 Phase III clinical trials.⁵ The S-enantiomer of ketamine is known to bind to the N-methyl-D-aspartate receptor stronger than the R-enantiomer.⁶ The mechanism of action of both stereoisomers on other receptors, such as opioid and alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA), is the focus of intensive research and remains to be fully elucidated, but initial studies indicate rapid neuroplasticity and synaptogenesis.⁷ What is clear is that this new intervention can provide relief to patients with TRD via a pharmacologically distinct mechanism.⁸

Ketamine may be administered intranasally, intravenously, or orally. A meta-analysis aimed at assessing differences in ketamine efficacy for depression based on route of administration have shown that both IV and IN ketamine are effective, though it is not possible to draw conclusions regarding a direct comparison based on available data.⁹ Despite several landmark published studies, such as those by Zarate et al,¹⁰ IV ketamine is not FDA-approved for TRD.

Continue to: Why psychiatrists?

Psychiatrists have been prescribing IN esketamine, which is covered by most commercial insurances and administered in certified healthcare settings under a Risk Evaluation and Mitigation Strategy program.⁵ However, anesthesiologists and emergency physicians have opened a crop of boutique and concierge health clinics offering various “packages” of IV ketamine infusions for a slew of mental ailments, including depression, anxiety, bipolar disorder, and posttraumatic stress disorder.¹¹ Minimal investigation reveals that these services are being prescribed mainly by practitioners in fields other than psychiatry. Intravenous ketamine has long been used off-label as a treatment for depression not by psychiatrists but by practitioners of anesthesiology or emergency medicine. Although these clinicians are likely familiar with ketamine as an anesthetic, they have no foundation or expertise in the diagnosis and treatment of complex mood disorders. The FDA-approved indication for esketamine falls firmly in the realm of psychiatric treatment. Physicians who have not completed a psychiatry residency have neither the training nor experience necessary to determine whether a patient is a candidate for this treatment.

One potential adverse effect of ketamine is an emergence phenomenon, colloquially named a “K-hole,” that can induce symptoms of psychosis such as disturbing hallucinations. Patients who have a history of psychosis need to be carefully evaluated for appropriateness to receive this treatment.

Furthermore, ketamine treatments administered by physicians who are not psychiatrists are billed not through insurance but mostly via private pay. A patient may therefore be charged $350 to $1,000 per infusion, to be paid out of pocket.¹¹ Tally that up over the standard 6 to 12 initial treatment infusions, followed by maintenance infusions, and these patients with profound depression are potentially building up significant debt. Does this practice align with the ethical principles of autonomy, justice, beneficence, and nonmaleficence that all physicians swore to uphold? Will psychiatrists take a stand against the financial exploitation of a vulnerable group that is desperate to find any potential relief from their depression?

Mobile applications (apps) have been a growing part of medicine for the last decade. In 2020, more than 15.5 million apps were available for download,¹ and more than 325,000 apps were health related.² Much of the peer-reviewed literature on health-related apps has focused on apps that target patients. Therefore, we studied apps for health care providers, specifically dermatology residents of different sexes throughout residency. We investigated the role of apps in their training, including how often residents consult apps, which apps they utilize, and why.

Methods

An original online survey regarding mobile apps was emailed to all 1587 dermatology residents in America by the American Academy of Dermatology from summer 2019 to summer 2020. Responses were anonymous, voluntary, unincentivized, and collected over 17 days. To protect respondent privacy, minimal data were collected regarding training programs; geography served as a proxy for how resource rich or resource poor those programs may be. Categorization of urban vs rural was based on the 2010 Census classification, such that Arizona; California; Colorado; Connecticut; Florida; Illinois; Maryland; Massachusetts; New Jersey; New York; Oregon; Puerto Rico; Rhode Island; Texas; Utah; and Washington, DC, were urban, and the remaining states were rural.³

We hypothesized that VisualDx would be 1 of 3 most prevalent apps; “diagnosis and workup” and “self-education” would be top reasons for using apps; “up-to-date and accurate information” would be a top 3 consideration when choosing apps; the most consulted resources for clinical experiences would be providers, followed by websites, apps, and lastly printed text; and the percentage of clinical experiences for which a provider was consulted would be higher for first-year residents than other years and for female residents than male residents.

Fisher exact 2-tailed and Kruskal-Wallis (KW) pairwise tests were used to compare groups. Statistical significance was set at P<.05.

Results

Respondents
The response rate was 16.6% (n=263), which is similar to prior response rates for American Academy of Dermatology surveys. Table 1 contains respondent demographics. The mean age of respondents was 31 years. Sixty percent of respondents were female; 62% of respondents were training in urban states or territories. Regarding the dermatology residency year, 34% of respondents were in their first year, 32% were in their second, and 34% were in their third. Eighty-seven percent of respondents used Apple iOS. Every respondent used at least 1 dermatology-related app (mean, 5; range, 1–11)(Table 2).

Top Dermatology-Related Apps
The 10 most prevalent apps are listed in Table 2. The 3 most prevalent apps were VisualDx (84%, majority of respondents used daily), UpToDate (67%, majority of respondents used daily), and Mohs Surgery Appropriate Use Criteria (63%, majority of respondents used weekly). A higher percentage of third-year residents used GoodRx compared to first- and second-year residents (Fisher exact test: P=.014 and P=.041, respectively). A lower percentage of female respondents used GoodRx compared to male residents (Fisher exact test: P=.003). None of the apps were app versions of printed text, including textbooks or journals.

Reasons for Using Apps
The 10 primary reasons for using apps are listed in Table 2. The top 3 reasons were diagnosis and workup (83%), medication dosage (72%), and self-education (69%). Medication dosage and saving time were both selected by a higher percentage of third-year residents than first-year residents (Fisher exact test: P=.041 and P=.024, respectively). Self-education was selected by a lower percentage of third-year residents than second-year residents (Fisher exact test: P=.025). 

Considerations When Choosing Apps
The 10 primary considerations when choosing apps are listed in Table 2. The top 3 considerations were up-to-date and accurate information (81%), no/low cost (80%), and user-friendly design (74%). Up-to-date and accurate information was selected by a lower percentage of third-year residents than first- and second-year residents (Fisher exact test: P=.02 and P=.03, respectively).

Consulted Resources
Apps were the second most consulted resource (26%) during clinical work, behind human guidance (73%). Female respondents consulted both resources more than male respondents (KW: P≤.005 and P≤.003, respectively). First-year residents consulted humans more than second-year and third-year residents (KW: P<.0001).

There were no significant differences by geography or mobile operating system.

Comment

The response rate and demographic results suggest that our study sample is representative of the target population of dermatology residents in America. Overall, the survey results support our hypotheses.

A survey conducted in 2008 before apps were readily available found that dermatology residents felt they learned more successfully when engaging in hands-on, direct experience; talking with experts/consultants; and studying printed materials than when using multimedia programs.⁴ Our study suggests that the usage of and preference for multimedia programs, including apps, in dermatology resident training has risen substantially, despite the continued availability of guidance from attendings and senior residents.

As residents progress through training, they increasingly turn to virtual resources. According to our survey, junior residents are more likely than third-year residents to use apps for self-education, and up-to-date and accurate information was a more important consideration when choosing apps. Third-year residents are more likely than junior residents to use apps for medication dosage and saving time. Perhaps related, GoodRx, an app that provides prescription discounts, was more prevalent among third-year residents. It is notable that most of the reported apps, including those used for diagnosis and treatment, did not need premarket government approval to ensure patient safety, are not required to contain up-to-date information, and do not reference primary sources. Additionally, only UpToDate has been shown in peer-reviewed literature to improve clinical outcomes.⁵

Our survey also revealed a few differences by sex. Female respondents consulted resources during clinical work more often than male residents. This finding is similar to the limited existing research on dermatologists’ utilization of information showing higher dermoscopy use among female attendings.⁶ Use of GoodRx was less prevalent among female vs male respondents. Perhaps related, a 2011 study found that female primary care physicians are less likely to prescribe medications than their male counterparts.⁷

Our study had several limitations. There may have been selection bias such that the residents who chose to participate were relatively more interested in mobile health. Certain demographic data, such as race, were not captured because prior studies do not suggest disparity by those demographics for mobile health utilization among residents, but those data could be incorporated into future studies. Our survey was intentionally limited in scope. For example, it did not capture the amount of time spent on each consult resource or the motivations for consulting an app instead of a provider.

Conclusion

A main objective of residency is to train new physicians to provide excellent patient care. Our survey highlights the increasing role of apps in dermatology residency, different priorities among years of residency, and different information utilization between sexes. This knowledge should encourage and help guide standardization and quality assurance of virtual residency education and integration of virtual resources into formal curricula. Residency administrators and residents should be aware of the apps used to learn and deliver care, consider the evidence for and regulation of those apps, and evaluate the accessibility and approachability of attendings to residents. Future research should examine the educational and clinical outcomes of app utilization among residents and the impact of residency programs’ unspoken cultures and expectations on relationships among residents of different demographics and their attendings.

Mobile applications (apps) have been a growing part of medicine for the last decade. In 2020, more than 15.5 million apps were available for download,¹ and more than 325,000 apps were health related.² Much of the peer-reviewed literature on health-related apps has focused on apps that target patients. Therefore, we studied apps for health care providers, specifically dermatology residents of different sexes throughout residency. We investigated the role of apps in their training, including how often residents consult apps, which apps they utilize, and why.

Methods

An original online survey regarding mobile apps was emailed to all 1587 dermatology residents in America by the American Academy of Dermatology from summer 2019 to summer 2020. Responses were anonymous, voluntary, unincentivized, and collected over 17 days. To protect respondent privacy, minimal data were collected regarding training programs; geography served as a proxy for how resource rich or resource poor those programs may be. Categorization of urban vs rural was based on the 2010 Census classification, such that Arizona; California; Colorado; Connecticut; Florida; Illinois; Maryland; Massachusetts; New Jersey; New York; Oregon; Puerto Rico; Rhode Island; Texas; Utah; and Washington, DC, were urban, and the remaining states were rural.³

We hypothesized that VisualDx would be 1 of 3 most prevalent apps; “diagnosis and workup” and “self-education” would be top reasons for using apps; “up-to-date and accurate information” would be a top 3 consideration when choosing apps; the most consulted resources for clinical experiences would be providers, followed by websites, apps, and lastly printed text; and the percentage of clinical experiences for which a provider was consulted would be higher for first-year residents than other years and for female residents than male residents.

Fisher exact 2-tailed and Kruskal-Wallis (KW) pairwise tests were used to compare groups. Statistical significance was set at P<.05.

Results

Respondents
The response rate was 16.6% (n=263), which is similar to prior response rates for American Academy of Dermatology surveys. Table 1 contains respondent demographics. The mean age of respondents was 31 years. Sixty percent of respondents were female; 62% of respondents were training in urban states or territories. Regarding the dermatology residency year, 34% of respondents were in their first year, 32% were in their second, and 34% were in their third. Eighty-seven percent of respondents used Apple iOS. Every respondent used at least 1 dermatology-related app (mean, 5; range, 1–11)(Table 2).

Top Dermatology-Related Apps
The 10 most prevalent apps are listed in Table 2. The 3 most prevalent apps were VisualDx (84%, majority of respondents used daily), UpToDate (67%, majority of respondents used daily), and Mohs Surgery Appropriate Use Criteria (63%, majority of respondents used weekly). A higher percentage of third-year residents used GoodRx compared to first- and second-year residents (Fisher exact test: P=.014 and P=.041, respectively). A lower percentage of female respondents used GoodRx compared to male residents (Fisher exact test: P=.003). None of the apps were app versions of printed text, including textbooks or journals.

Reasons for Using Apps
The 10 primary reasons for using apps are listed in Table 2. The top 3 reasons were diagnosis and workup (83%), medication dosage (72%), and self-education (69%). Medication dosage and saving time were both selected by a higher percentage of third-year residents than first-year residents (Fisher exact test: P=.041 and P=.024, respectively). Self-education was selected by a lower percentage of third-year residents than second-year residents (Fisher exact test: P=.025). 

Considerations When Choosing Apps
The 10 primary considerations when choosing apps are listed in Table 2. The top 3 considerations were up-to-date and accurate information (81%), no/low cost (80%), and user-friendly design (74%). Up-to-date and accurate information was selected by a lower percentage of third-year residents than first- and second-year residents (Fisher exact test: P=.02 and P=.03, respectively).

Consulted Resources
Apps were the second most consulted resource (26%) during clinical work, behind human guidance (73%). Female respondents consulted both resources more than male respondents (KW: P≤.005 and P≤.003, respectively). First-year residents consulted humans more than second-year and third-year residents (KW: P<.0001).

There were no significant differences by geography or mobile operating system.

Comment

The response rate and demographic results suggest that our study sample is representative of the target population of dermatology residents in America. Overall, the survey results support our hypotheses.

A survey conducted in 2008 before apps were readily available found that dermatology residents felt they learned more successfully when engaging in hands-on, direct experience; talking with experts/consultants; and studying printed materials than when using multimedia programs.⁴ Our study suggests that the usage of and preference for multimedia programs, including apps, in dermatology resident training has risen substantially, despite the continued availability of guidance from attendings and senior residents.

As residents progress through training, they increasingly turn to virtual resources. According to our survey, junior residents are more likely than third-year residents to use apps for self-education, and up-to-date and accurate information was a more important consideration when choosing apps. Third-year residents are more likely than junior residents to use apps for medication dosage and saving time. Perhaps related, GoodRx, an app that provides prescription discounts, was more prevalent among third-year residents. It is notable that most of the reported apps, including those used for diagnosis and treatment, did not need premarket government approval to ensure patient safety, are not required to contain up-to-date information, and do not reference primary sources. Additionally, only UpToDate has been shown in peer-reviewed literature to improve clinical outcomes.⁵

Our survey also revealed a few differences by sex. Female respondents consulted resources during clinical work more often than male residents. This finding is similar to the limited existing research on dermatologists’ utilization of information showing higher dermoscopy use among female attendings.⁶ Use of GoodRx was less prevalent among female vs male respondents. Perhaps related, a 2011 study found that female primary care physicians are less likely to prescribe medications than their male counterparts.⁷

Our study had several limitations. There may have been selection bias such that the residents who chose to participate were relatively more interested in mobile health. Certain demographic data, such as race, were not captured because prior studies do not suggest disparity by those demographics for mobile health utilization among residents, but those data could be incorporated into future studies. Our survey was intentionally limited in scope. For example, it did not capture the amount of time spent on each consult resource or the motivations for consulting an app instead of a provider.

Conclusion

A main objective of residency is to train new physicians to provide excellent patient care. Our survey highlights the increasing role of apps in dermatology residency, different priorities among years of residency, and different information utilization between sexes. This knowledge should encourage and help guide standardization and quality assurance of virtual residency education and integration of virtual resources into formal curricula. Residency administrators and residents should be aware of the apps used to learn and deliver care, consider the evidence for and regulation of those apps, and evaluate the accessibility and approachability of attendings to residents. Future research should examine the educational and clinical outcomes of app utilization among residents and the impact of residency programs’ unspoken cultures and expectations on relationships among residents of different demographics and their attendings.

Mobile applications (apps) have been a growing part of medicine for the last decade. In 2020, more than 15.5 million apps were available for download,¹ and more than 325,000 apps were health related.² Much of the peer-reviewed literature on health-related apps has focused on apps that target patients. Therefore, we studied apps for health care providers, specifically dermatology residents of different sexes throughout residency. We investigated the role of apps in their training, including how often residents consult apps, which apps they utilize, and why.

Methods

An original online survey regarding mobile apps was emailed to all 1587 dermatology residents in America by the American Academy of Dermatology from summer 2019 to summer 2020. Responses were anonymous, voluntary, unincentivized, and collected over 17 days. To protect respondent privacy, minimal data were collected regarding training programs; geography served as a proxy for how resource rich or resource poor those programs may be. Categorization of urban vs rural was based on the 2010 Census classification, such that Arizona; California; Colorado; Connecticut; Florida; Illinois; Maryland; Massachusetts; New Jersey; New York; Oregon; Puerto Rico; Rhode Island; Texas; Utah; and Washington, DC, were urban, and the remaining states were rural.³

We hypothesized that VisualDx would be 1 of 3 most prevalent apps; “diagnosis and workup” and “self-education” would be top reasons for using apps; “up-to-date and accurate information” would be a top 3 consideration when choosing apps; the most consulted resources for clinical experiences would be providers, followed by websites, apps, and lastly printed text; and the percentage of clinical experiences for which a provider was consulted would be higher for first-year residents than other years and for female residents than male residents.

Fisher exact 2-tailed and Kruskal-Wallis (KW) pairwise tests were used to compare groups. Statistical significance was set at P<.05.

Results

Respondents
The response rate was 16.6% (n=263), which is similar to prior response rates for American Academy of Dermatology surveys. Table 1 contains respondent demographics. The mean age of respondents was 31 years. Sixty percent of respondents were female; 62% of respondents were training in urban states or territories. Regarding the dermatology residency year, 34% of respondents were in their first year, 32% were in their second, and 34% were in their third. Eighty-seven percent of respondents used Apple iOS. Every respondent used at least 1 dermatology-related app (mean, 5; range, 1–11)(Table 2).

Top Dermatology-Related Apps
The 10 most prevalent apps are listed in Table 2. The 3 most prevalent apps were VisualDx (84%, majority of respondents used daily), UpToDate (67%, majority of respondents used daily), and Mohs Surgery Appropriate Use Criteria (63%, majority of respondents used weekly). A higher percentage of third-year residents used GoodRx compared to first- and second-year residents (Fisher exact test: P=.014 and P=.041, respectively). A lower percentage of female respondents used GoodRx compared to male residents (Fisher exact test: P=.003). None of the apps were app versions of printed text, including textbooks or journals.

Reasons for Using Apps
The 10 primary reasons for using apps are listed in Table 2. The top 3 reasons were diagnosis and workup (83%), medication dosage (72%), and self-education (69%). Medication dosage and saving time were both selected by a higher percentage of third-year residents than first-year residents (Fisher exact test: P=.041 and P=.024, respectively). Self-education was selected by a lower percentage of third-year residents than second-year residents (Fisher exact test: P=.025). 

Considerations When Choosing Apps
The 10 primary considerations when choosing apps are listed in Table 2. The top 3 considerations were up-to-date and accurate information (81%), no/low cost (80%), and user-friendly design (74%). Up-to-date and accurate information was selected by a lower percentage of third-year residents than first- and second-year residents (Fisher exact test: P=.02 and P=.03, respectively).

Consulted Resources
Apps were the second most consulted resource (26%) during clinical work, behind human guidance (73%). Female respondents consulted both resources more than male respondents (KW: P≤.005 and P≤.003, respectively). First-year residents consulted humans more than second-year and third-year residents (KW: P<.0001).

There were no significant differences by geography or mobile operating system.

Comment

The response rate and demographic results suggest that our study sample is representative of the target population of dermatology residents in America. Overall, the survey results support our hypotheses.

A survey conducted in 2008 before apps were readily available found that dermatology residents felt they learned more successfully when engaging in hands-on, direct experience; talking with experts/consultants; and studying printed materials than when using multimedia programs.⁴ Our study suggests that the usage of and preference for multimedia programs, including apps, in dermatology resident training has risen substantially, despite the continued availability of guidance from attendings and senior residents.

As residents progress through training, they increasingly turn to virtual resources. According to our survey, junior residents are more likely than third-year residents to use apps for self-education, and up-to-date and accurate information was a more important consideration when choosing apps. Third-year residents are more likely than junior residents to use apps for medication dosage and saving time. Perhaps related, GoodRx, an app that provides prescription discounts, was more prevalent among third-year residents. It is notable that most of the reported apps, including those used for diagnosis and treatment, did not need premarket government approval to ensure patient safety, are not required to contain up-to-date information, and do not reference primary sources. Additionally, only UpToDate has been shown in peer-reviewed literature to improve clinical outcomes.⁵

Our survey also revealed a few differences by sex. Female respondents consulted resources during clinical work more often than male residents. This finding is similar to the limited existing research on dermatologists’ utilization of information showing higher dermoscopy use among female attendings.⁶ Use of GoodRx was less prevalent among female vs male respondents. Perhaps related, a 2011 study found that female primary care physicians are less likely to prescribe medications than their male counterparts.⁷

Our study had several limitations. There may have been selection bias such that the residents who chose to participate were relatively more interested in mobile health. Certain demographic data, such as race, were not captured because prior studies do not suggest disparity by those demographics for mobile health utilization among residents, but those data could be incorporated into future studies. Our survey was intentionally limited in scope. For example, it did not capture the amount of time spent on each consult resource or the motivations for consulting an app instead of a provider.

Conclusion

A main objective of residency is to train new physicians to provide excellent patient care. Our survey highlights the increasing role of apps in dermatology residency, different priorities among years of residency, and different information utilization between sexes. This knowledge should encourage and help guide standardization and quality assurance of virtual residency education and integration of virtual resources into formal curricula. Residency administrators and residents should be aware of the apps used to learn and deliver care, consider the evidence for and regulation of those apps, and evaluate the accessibility and approachability of attendings to residents. Future research should examine the educational and clinical outcomes of app utilization among residents and the impact of residency programs’ unspoken cultures and expectations on relationships among residents of different demographics and their attendings.

As a psychiatry resident and as a part of consultation-liaison service, I have visited many palliative care patients to assist other physicians in managing psychiatric issues such as depression, anxiety, or delirium. But recently, as the first resident from our Department of Psychiatry who was sent to a palliative care rotation, I followed these patients as a part of a primary palliative care team. Doing so allowed me to see patients from the other side of the bridge.

Palliative care focuses on providing relief from the suffering and stress of a patient’s illness, with the primary goal of improving the quality of life of the patient and their families. The palliative care team works in collaboration with the patient’s other clinicians to provide an extra layer of support. They provide biopsychosociocultural interventions that are in harmony with the needs of the patient rather than the prognosis of the illness. To do so, they first must evaluate the needs of the patient and their family. This is a time-consuming, energy-consuming, emotionally draining job.

During my palliative care rotation, I attended table rounds, bedside rounds, family meetings, long counseling sessions, and disposition planning meetings. This rotation also gave me the opportunity to place my feet in the shoes of a palliative care team and to reflect on how it feels to be the physician of a patient who is dying, which as a psychiatric resident I had seldom experienced. I learned that although working with patients who are dying can cause stress, burnout, and compassion fatigue, it also helps physicians appreciate the little things in life. To appreciate all the blessings we have that we usually take for granted. To practice gratitude. To be kind.

Upon reflection, I learned that the rounds of palliative care are actually mindfulness-based discussions that provide cushions of supportive work, facilitate feelings of being in control, tend to alleviate physical as well as mental suffering, foster clear-sighted hope, and assist in establishing small, subjectively significant, realistic goals for the patient’s immediate future, and to help the patient achieve these goals.

A valuable lesson from a patient

I want to highlight a case of a 65-year-old woman I first visited while I was shadowing my attending, who had been providing palliative care to the patient and her family for several months. The patient was admitted to a tertiary care hospital because cancer had invaded her small bowel and caused mechanical obstruction, resulting in intractable vomiting, abdominal distension, and anorexia. She underwent open laparotomy and ileostomy for symptomatic relief. A nasogastric tube was placed, and she was put on total parenteral nutrition. The day I met her was her third postoperative day. She had been improving significantly, and she wanted to eat. She was missing food. Most of the discussion in the round among my attending, the patient, and her family was centered around how to get to the point where she would be able to eat again and appreciate the taste of biryani.

What my attending did was incredible. After assessing the patient’s needs, he instilled a realistic hope: the hope of tasting food again. The attending, while acknowledging the patient’s apprehensions, respectfully and supportively kept her from wandering into the future, made every possible attempt to bring her attention back to the present moment, and helped her establish goals for the present and her immediate future. My attending was not toxic-positive, forcing his patient to uselessly revisit her current trauma. Instead, he was kind, empathic, and considerate. His primary focus was to understand rather than to be understood, to help her find meaning, and to improve her quality of life—a quality she defined for herself, which was to taste the food of her choice.

That day, when I returned to my working station in the psychiatry ward and had lunch in the break room, I thought, “When I eat, how often do I think about eating?” Mostly I either think about work, tasks, and presentations, or I scroll on social media.

Our taste buds indeed get adapted to repetitive stimulation, but the experience of eating our favorite dish is the naked truth of being alive, and is something that I have been taking for granted for a long time. These are little things in life that I need to appreciate, and learn to cultivate their power.

As a psychiatry resident and as a part of consultation-liaison service, I have visited many palliative care patients to assist other physicians in managing psychiatric issues such as depression, anxiety, or delirium. But recently, as the first resident from our Department of Psychiatry who was sent to a palliative care rotation, I followed these patients as a part of a primary palliative care team. Doing so allowed me to see patients from the other side of the bridge.

Palliative care focuses on providing relief from the suffering and stress of a patient’s illness, with the primary goal of improving the quality of life of the patient and their families. The palliative care team works in collaboration with the patient’s other clinicians to provide an extra layer of support. They provide biopsychosociocultural interventions that are in harmony with the needs of the patient rather than the prognosis of the illness. To do so, they first must evaluate the needs of the patient and their family. This is a time-consuming, energy-consuming, emotionally draining job.

During my palliative care rotation, I attended table rounds, bedside rounds, family meetings, long counseling sessions, and disposition planning meetings. This rotation also gave me the opportunity to place my feet in the shoes of a palliative care team and to reflect on how it feels to be the physician of a patient who is dying, which as a psychiatric resident I had seldom experienced. I learned that although working with patients who are dying can cause stress, burnout, and compassion fatigue, it also helps physicians appreciate the little things in life. To appreciate all the blessings we have that we usually take for granted. To practice gratitude. To be kind.

Upon reflection, I learned that the rounds of palliative care are actually mindfulness-based discussions that provide cushions of supportive work, facilitate feelings of being in control, tend to alleviate physical as well as mental suffering, foster clear-sighted hope, and assist in establishing small, subjectively significant, realistic goals for the patient’s immediate future, and to help the patient achieve these goals.

A valuable lesson from a patient

I want to highlight a case of a 65-year-old woman I first visited while I was shadowing my attending, who had been providing palliative care to the patient and her family for several months. The patient was admitted to a tertiary care hospital because cancer had invaded her small bowel and caused mechanical obstruction, resulting in intractable vomiting, abdominal distension, and anorexia. She underwent open laparotomy and ileostomy for symptomatic relief. A nasogastric tube was placed, and she was put on total parenteral nutrition. The day I met her was her third postoperative day. She had been improving significantly, and she wanted to eat. She was missing food. Most of the discussion in the round among my attending, the patient, and her family was centered around how to get to the point where she would be able to eat again and appreciate the taste of biryani.

What my attending did was incredible. After assessing the patient’s needs, he instilled a realistic hope: the hope of tasting food again. The attending, while acknowledging the patient’s apprehensions, respectfully and supportively kept her from wandering into the future, made every possible attempt to bring her attention back to the present moment, and helped her establish goals for the present and her immediate future. My attending was not toxic-positive, forcing his patient to uselessly revisit her current trauma. Instead, he was kind, empathic, and considerate. His primary focus was to understand rather than to be understood, to help her find meaning, and to improve her quality of life—a quality she defined for herself, which was to taste the food of her choice.

That day, when I returned to my working station in the psychiatry ward and had lunch in the break room, I thought, “When I eat, how often do I think about eating?” Mostly I either think about work, tasks, and presentations, or I scroll on social media.

Our taste buds indeed get adapted to repetitive stimulation, but the experience of eating our favorite dish is the naked truth of being alive, and is something that I have been taking for granted for a long time. These are little things in life that I need to appreciate, and learn to cultivate their power.

As a psychiatry resident and as a part of consultation-liaison service, I have visited many palliative care patients to assist other physicians in managing psychiatric issues such as depression, anxiety, or delirium. But recently, as the first resident from our Department of Psychiatry who was sent to a palliative care rotation, I followed these patients as a part of a primary palliative care team. Doing so allowed me to see patients from the other side of the bridge.

Palliative care focuses on providing relief from the suffering and stress of a patient’s illness, with the primary goal of improving the quality of life of the patient and their families. The palliative care team works in collaboration with the patient’s other clinicians to provide an extra layer of support. They provide biopsychosociocultural interventions that are in harmony with the needs of the patient rather than the prognosis of the illness. To do so, they first must evaluate the needs of the patient and their family. This is a time-consuming, energy-consuming, emotionally draining job.

During my palliative care rotation, I attended table rounds, bedside rounds, family meetings, long counseling sessions, and disposition planning meetings. This rotation also gave me the opportunity to place my feet in the shoes of a palliative care team and to reflect on how it feels to be the physician of a patient who is dying, which as a psychiatric resident I had seldom experienced. I learned that although working with patients who are dying can cause stress, burnout, and compassion fatigue, it also helps physicians appreciate the little things in life. To appreciate all the blessings we have that we usually take for granted. To practice gratitude. To be kind.

Upon reflection, I learned that the rounds of palliative care are actually mindfulness-based discussions that provide cushions of supportive work, facilitate feelings of being in control, tend to alleviate physical as well as mental suffering, foster clear-sighted hope, and assist in establishing small, subjectively significant, realistic goals for the patient’s immediate future, and to help the patient achieve these goals.

A valuable lesson from a patient

I want to highlight a case of a 65-year-old woman I first visited while I was shadowing my attending, who had been providing palliative care to the patient and her family for several months. The patient was admitted to a tertiary care hospital because cancer had invaded her small bowel and caused mechanical obstruction, resulting in intractable vomiting, abdominal distension, and anorexia. She underwent open laparotomy and ileostomy for symptomatic relief. A nasogastric tube was placed, and she was put on total parenteral nutrition. The day I met her was her third postoperative day. She had been improving significantly, and she wanted to eat. She was missing food. Most of the discussion in the round among my attending, the patient, and her family was centered around how to get to the point where she would be able to eat again and appreciate the taste of biryani.

What my attending did was incredible. After assessing the patient’s needs, he instilled a realistic hope: the hope of tasting food again. The attending, while acknowledging the patient’s apprehensions, respectfully and supportively kept her from wandering into the future, made every possible attempt to bring her attention back to the present moment, and helped her establish goals for the present and her immediate future. My attending was not toxic-positive, forcing his patient to uselessly revisit her current trauma. Instead, he was kind, empathic, and considerate. His primary focus was to understand rather than to be understood, to help her find meaning, and to improve her quality of life—a quality she defined for herself, which was to taste the food of her choice.

That day, when I returned to my working station in the psychiatry ward and had lunch in the break room, I thought, “When I eat, how often do I think about eating?” Mostly I either think about work, tasks, and presentations, or I scroll on social media.

Our taste buds indeed get adapted to repetitive stimulation, but the experience of eating our favorite dish is the naked truth of being alive, and is something that I have been taking for granted for a long time. These are little things in life that I need to appreciate, and learn to cultivate their power.

At morning shift change a few months ago on my consultation-liaison rotation, I thanked the night float resident who had been called to a case that was not at all psychiatrically acute. When I told my colleague I was sorry she had had such a “soft consult” during a busy shift, she graciously replied that the patient had been exceedingly pleasant. She said, “Sometimes we just offer our presence, and you know what? I’m glad I’m in that kind of field. The ‘being-present’ kind of field.”

As mental health professionals, we pride ourselves on being present for our patients and our colleagues alike. Winnicott¹ originally coined the psychoanalytic term “holding” to denote one of the earliest stages of parental care, wherein an environment of both physical and emotional reliability allows a child to develop their sense of self. The complementary concept of “containing,” developed by Bion,² indicates a parental figure’s receiving the child’s emotions, however difficult, and then processing them into a more tolerable form. I am frequently struck by how often our role as psychiatrists is not necessarily to offer a specific diagnosis or medication recommendation, but instead to “hold” by listening, “contain” whatever emotions emerge, and offer a sense of validation and perhaps a biopsychosocial formulation for the patient’s experience.^3-5 In the consultation-liaison setting, we might assess the contribution of sleep cycle disturbance, postoperative opioids, and anticholinergic medications on a patient’s mental status. Just as important, we might help the patient and their primary team understand that the patient’s history of childhood trauma could, under stressful conditions such as a prolonged hospitalization, lead to affective dysregulation and result in projective identification through which the team felt just as frustrated and helpless as the patient.

The relentless pursuit of efficiency vs time spent with patients

In inpatient work, I may serve as short-term psychotherapist for the patient, their family members, or a consulting team, and I treasure the time spent in those roles. But I concurrently hold various other responsibilities during my shift, including the roles of triage clinician, medical ethicist, and psychopharmacology expert (or, in the case of a newly-third-year resident such as myself, a nonexpert trying to build her knowledge base). I am also literally holding a pager, which intrudes—with aggressive cacophony, vibration, or both—upon the sanctity of any space. The pager is a reminder of a myriad of tasks: calling collateral, answering questions from team members, pre-charting, note-writing, ordering labs, checking labs, updating the handoff, reconciling medication lists, filling out legal paperwork, triaging the next consult. These are unavoidable and generally necessary parts of clinical work, but sometimes they veer into sheer drudgery.

As a medical student, learning to complete tasks is a substantial part of each clinical rotation, and task completion provides plenty of dopaminergic reinforcements that could masquerade as job satisfaction. Through my first year and a half of residency, I pushed hard to build “efficiency” in my workflow, but eventually, task completion stopped providing sufficient inherent satisfaction. It has been a relief to find that amid the stream of checkboxes, the true work of psychiatric care (the interactions with patients, their clinical presentations, and considering their differential diagnoses and treatment options) feels deeply meaningful and ever more fascinating.

At times, I am angered by the reality of limited clinician bandwidth. This frustration motivates me to seek system-level improvements that can enable us to deliver quality psychiatric care while mitigating the risk of clinician burnout. What ends up shortchanged in the relentless pursuit of efficiency is the time spent with patients. This is never more apparent than during a busy inpatient shift, when I often need to compress patient interactions and focus only on the most acute clinical questions. When I have to apologize for stepping out of the interview room to answer yet another page, I marvel at seeing attending psychiatrists who—with apparent ease—make patients feel as if they have all the time in the world, and I wonder when I will be able to do the same.

And yet, there are other times when my pager stays blessedly quiet, time can slow down in the room, and I can make a patient feel heard, held, and contained. In those moments, I also hold my own need for connection with the patient, and can recall what my colleague reminded me: what a privilege it is to be in the “being-present” kind of field.

At morning shift change a few months ago on my consultation-liaison rotation, I thanked the night float resident who had been called to a case that was not at all psychiatrically acute. When I told my colleague I was sorry she had had such a “soft consult” during a busy shift, she graciously replied that the patient had been exceedingly pleasant. She said, “Sometimes we just offer our presence, and you know what? I’m glad I’m in that kind of field. The ‘being-present’ kind of field.”

As mental health professionals, we pride ourselves on being present for our patients and our colleagues alike. Winnicott¹ originally coined the psychoanalytic term “holding” to denote one of the earliest stages of parental care, wherein an environment of both physical and emotional reliability allows a child to develop their sense of self. The complementary concept of “containing,” developed by Bion,² indicates a parental figure’s receiving the child’s emotions, however difficult, and then processing them into a more tolerable form. I am frequently struck by how often our role as psychiatrists is not necessarily to offer a specific diagnosis or medication recommendation, but instead to “hold” by listening, “contain” whatever emotions emerge, and offer a sense of validation and perhaps a biopsychosocial formulation for the patient’s experience.^3-5 In the consultation-liaison setting, we might assess the contribution of sleep cycle disturbance, postoperative opioids, and anticholinergic medications on a patient’s mental status. Just as important, we might help the patient and their primary team understand that the patient’s history of childhood trauma could, under stressful conditions such as a prolonged hospitalization, lead to affective dysregulation and result in projective identification through which the team felt just as frustrated and helpless as the patient.

The relentless pursuit of efficiency vs time spent with patients

In inpatient work, I may serve as short-term psychotherapist for the patient, their family members, or a consulting team, and I treasure the time spent in those roles. But I concurrently hold various other responsibilities during my shift, including the roles of triage clinician, medical ethicist, and psychopharmacology expert (or, in the case of a newly-third-year resident such as myself, a nonexpert trying to build her knowledge base). I am also literally holding a pager, which intrudes—with aggressive cacophony, vibration, or both—upon the sanctity of any space. The pager is a reminder of a myriad of tasks: calling collateral, answering questions from team members, pre-charting, note-writing, ordering labs, checking labs, updating the handoff, reconciling medication lists, filling out legal paperwork, triaging the next consult. These are unavoidable and generally necessary parts of clinical work, but sometimes they veer into sheer drudgery.

As a medical student, learning to complete tasks is a substantial part of each clinical rotation, and task completion provides plenty of dopaminergic reinforcements that could masquerade as job satisfaction. Through my first year and a half of residency, I pushed hard to build “efficiency” in my workflow, but eventually, task completion stopped providing sufficient inherent satisfaction. It has been a relief to find that amid the stream of checkboxes, the true work of psychiatric care (the interactions with patients, their clinical presentations, and considering their differential diagnoses and treatment options) feels deeply meaningful and ever more fascinating.

At times, I am angered by the reality of limited clinician bandwidth. This frustration motivates me to seek system-level improvements that can enable us to deliver quality psychiatric care while mitigating the risk of clinician burnout. What ends up shortchanged in the relentless pursuit of efficiency is the time spent with patients. This is never more apparent than during a busy inpatient shift, when I often need to compress patient interactions and focus only on the most acute clinical questions. When I have to apologize for stepping out of the interview room to answer yet another page, I marvel at seeing attending psychiatrists who—with apparent ease—make patients feel as if they have all the time in the world, and I wonder when I will be able to do the same.

And yet, there are other times when my pager stays blessedly quiet, time can slow down in the room, and I can make a patient feel heard, held, and contained. In those moments, I also hold my own need for connection with the patient, and can recall what my colleague reminded me: what a privilege it is to be in the “being-present” kind of field.

At morning shift change a few months ago on my consultation-liaison rotation, I thanked the night float resident who had been called to a case that was not at all psychiatrically acute. When I told my colleague I was sorry she had had such a “soft consult” during a busy shift, she graciously replied that the patient had been exceedingly pleasant. She said, “Sometimes we just offer our presence, and you know what? I’m glad I’m in that kind of field. The ‘being-present’ kind of field.”

As mental health professionals, we pride ourselves on being present for our patients and our colleagues alike. Winnicott¹ originally coined the psychoanalytic term “holding” to denote one of the earliest stages of parental care, wherein an environment of both physical and emotional reliability allows a child to develop their sense of self. The complementary concept of “containing,” developed by Bion,² indicates a parental figure’s receiving the child’s emotions, however difficult, and then processing them into a more tolerable form. I am frequently struck by how often our role as psychiatrists is not necessarily to offer a specific diagnosis or medication recommendation, but instead to “hold” by listening, “contain” whatever emotions emerge, and offer a sense of validation and perhaps a biopsychosocial formulation for the patient’s experience.^3-5 In the consultation-liaison setting, we might assess the contribution of sleep cycle disturbance, postoperative opioids, and anticholinergic medications on a patient’s mental status. Just as important, we might help the patient and their primary team understand that the patient’s history of childhood trauma could, under stressful conditions such as a prolonged hospitalization, lead to affective dysregulation and result in projective identification through which the team felt just as frustrated and helpless as the patient.

The relentless pursuit of efficiency vs time spent with patients

In inpatient work, I may serve as short-term psychotherapist for the patient, their family members, or a consulting team, and I treasure the time spent in those roles. But I concurrently hold various other responsibilities during my shift, including the roles of triage clinician, medical ethicist, and psychopharmacology expert (or, in the case of a newly-third-year resident such as myself, a nonexpert trying to build her knowledge base). I am also literally holding a pager, which intrudes—with aggressive cacophony, vibration, or both—upon the sanctity of any space. The pager is a reminder of a myriad of tasks: calling collateral, answering questions from team members, pre-charting, note-writing, ordering labs, checking labs, updating the handoff, reconciling medication lists, filling out legal paperwork, triaging the next consult. These are unavoidable and generally necessary parts of clinical work, but sometimes they veer into sheer drudgery.

As a medical student, learning to complete tasks is a substantial part of each clinical rotation, and task completion provides plenty of dopaminergic reinforcements that could masquerade as job satisfaction. Through my first year and a half of residency, I pushed hard to build “efficiency” in my workflow, but eventually, task completion stopped providing sufficient inherent satisfaction. It has been a relief to find that amid the stream of checkboxes, the true work of psychiatric care (the interactions with patients, their clinical presentations, and considering their differential diagnoses and treatment options) feels deeply meaningful and ever more fascinating.

At times, I am angered by the reality of limited clinician bandwidth. This frustration motivates me to seek system-level improvements that can enable us to deliver quality psychiatric care while mitigating the risk of clinician burnout. What ends up shortchanged in the relentless pursuit of efficiency is the time spent with patients. This is never more apparent than during a busy inpatient shift, when I often need to compress patient interactions and focus only on the most acute clinical questions. When I have to apologize for stepping out of the interview room to answer yet another page, I marvel at seeing attending psychiatrists who—with apparent ease—make patients feel as if they have all the time in the world, and I wonder when I will be able to do the same.

And yet, there are other times when my pager stays blessedly quiet, time can slow down in the room, and I can make a patient feel heard, held, and contained. In those moments, I also hold my own need for connection with the patient, and can recall what my colleague reminded me: what a privilege it is to be in the “being-present” kind of field.

The Accreditation Council for Graduate Medical Education has established core competencies to serve as a foundation for the training received in a dermatology residency program.¹ Although programs are required to have the same concentrations—patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice—no specific guidelines are in place regarding how each of these competencies should be reached within a training period.² Instead, it remains the responsibility of each program to formulate an individualized curriculum to facilitate proficiency in the multiple areas encompassed by a residency.

In many dermatology residency programs, dermatopathology is a substantial component of educational objectives and the curriculum.¹ Residents may spend as much as 25% of their training on dermatopathology. However, there is great variability among programs in methods of teaching dermatopathology. When Hinshaw³ surveyed 52 of 109 dermatology residency programs, they identified differences in dermatopathology teaching that included, but was not limited to, utilization of problem-based learning (in 40.4% of programs), integration of journal reviews (53.8%), and computer-based learning (19.2%). In addition, differences were identified in the recommended primary textbook and the makeup of faculty who taught dermatopathology.³

Although residency programs vary in their methods of teaching this important component of dermatology, most use a multiheaded microscope in some capacity for didactics or sign-out. For most trainees, the dermatopathology laboratory is a new environment compared to the clinical space that medical students and residents become accustomed to throughout their education, thus creating a knowledge gap for trainees on proper dermatopathology etiquette and universal guidelines.

With medical students, residents, and fellows in mind, we have prepared a basic “dermatopathology etiquette” reference for trainees. Just as there are universal rules in the operating room for surgery (eg, sterile technique), we want to establish a code of conduct at the microscope. We hope that these 10 tips will, first, be useful to those who are unsure how to approach their first experience with dermatopathology and, second, serve as a guideline to aid development of appropriate communication skills and functioning within this novel setting. This list also can serve as a resource for dermatopathology attendings to provide to rotating residents and students.

1. New to pathology? It’s okay to ask. Do not hesitate to ask upper-year residents, fellows, and attendings for instructions on such matters as how to adjust your eyepiece to get the best resolution. 

2. If a slide drops on the floor, do not move! Your first instinct might be to move your chair to look for the dropped slide, but you might roll over it and break it.

3. When the attending is looking through the scope, you look through the scope. Dermatopathology is a visual exercise. Getting in your “optic mileage” is best done under the guidance of an experienced dermatopathologist.

4. Rules regarding food and drink at the microscope vary by pathologist. It’s best to ask what each attending prefers. Safe advice is to avoid foods that make noise, such as chewing gum and chips, and food that has a strong odor, such as microwaved leftovers.

5. Limit use of a laptop, cell phone, and smartwatch. If you think that using any of these is necessary, it generally is best to announce that you are looking up something related to the case and then share your findings (but not the most recent post on your Facebook News Feed).

6. If you notice that something needs correcting on the report, speak up! We are all human; we all make typos. Do not hesitate to mention this as soon as possible, especially before the case is signed out. You will likely be thanked by your attending because it is harder to rectify once the report has been signed out.

7. Small talk often is welcome during large excisions. This is a great time to ask what others are doing next weekend or what happened in clinic earlier that day, or just to tell a good (clean) joke that is making the rounds. Conversely, if the case is complex, it often is best to wait until it is completed before asking questions.

8. When participating in a roundtable diagnosis, you are welcome to directly state the diagnosis for bread-and-butter cases, such as basal cell carcinomas and seborrheic keratoses. It is appropriate to be more descriptive and methodical in more complex cases. When evaluating a rash, give the general inflammatory pattern first. For example, is it spongiotic? Psoriasiform? Interface? Or a mixed pattern?

9. Extra points for identifying special sites! These include mucosal, genital, and acral sites. You might even get bonus points if you can determine something about the patient (child or adult) based on the pathologic features, such as variation in collagen patterns.

10. Whenever you are in doubt, just describe what you see. You can use the traditional top-down approach or start with stating the most evident finding, then proceed to a top-down description. If it is a neoplasm, describe the overall architecture; then, what you see at a cellular level will get you some points as well.

We acknowledge that this list of 10 tips is not comprehensive and might vary by attending and each institution’s distinctive training format. We are hopeful, however, that these 10 points of etiquette can serve as a guideline.

The Accreditation Council for Graduate Medical Education has established core competencies to serve as a foundation for the training received in a dermatology residency program.¹ Although programs are required to have the same concentrations—patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice—no specific guidelines are in place regarding how each of these competencies should be reached within a training period.² Instead, it remains the responsibility of each program to formulate an individualized curriculum to facilitate proficiency in the multiple areas encompassed by a residency.

In many dermatology residency programs, dermatopathology is a substantial component of educational objectives and the curriculum.¹ Residents may spend as much as 25% of their training on dermatopathology. However, there is great variability among programs in methods of teaching dermatopathology. When Hinshaw³ surveyed 52 of 109 dermatology residency programs, they identified differences in dermatopathology teaching that included, but was not limited to, utilization of problem-based learning (in 40.4% of programs), integration of journal reviews (53.8%), and computer-based learning (19.2%). In addition, differences were identified in the recommended primary textbook and the makeup of faculty who taught dermatopathology.³

Although residency programs vary in their methods of teaching this important component of dermatology, most use a multiheaded microscope in some capacity for didactics or sign-out. For most trainees, the dermatopathology laboratory is a new environment compared to the clinical space that medical students and residents become accustomed to throughout their education, thus creating a knowledge gap for trainees on proper dermatopathology etiquette and universal guidelines.

With medical students, residents, and fellows in mind, we have prepared a basic “dermatopathology etiquette” reference for trainees. Just as there are universal rules in the operating room for surgery (eg, sterile technique), we want to establish a code of conduct at the microscope. We hope that these 10 tips will, first, be useful to those who are unsure how to approach their first experience with dermatopathology and, second, serve as a guideline to aid development of appropriate communication skills and functioning within this novel setting. This list also can serve as a resource for dermatopathology attendings to provide to rotating residents and students.

1. New to pathology? It’s okay to ask. Do not hesitate to ask upper-year residents, fellows, and attendings for instructions on such matters as how to adjust your eyepiece to get the best resolution. 

2. If a slide drops on the floor, do not move! Your first instinct might be to move your chair to look for the dropped slide, but you might roll over it and break it.

3. When the attending is looking through the scope, you look through the scope. Dermatopathology is a visual exercise. Getting in your “optic mileage” is best done under the guidance of an experienced dermatopathologist.

4. Rules regarding food and drink at the microscope vary by pathologist. It’s best to ask what each attending prefers. Safe advice is to avoid foods that make noise, such as chewing gum and chips, and food that has a strong odor, such as microwaved leftovers.

5. Limit use of a laptop, cell phone, and smartwatch. If you think that using any of these is necessary, it generally is best to announce that you are looking up something related to the case and then share your findings (but not the most recent post on your Facebook News Feed).

6. If you notice that something needs correcting on the report, speak up! We are all human; we all make typos. Do not hesitate to mention this as soon as possible, especially before the case is signed out. You will likely be thanked by your attending because it is harder to rectify once the report has been signed out.

7. Small talk often is welcome during large excisions. This is a great time to ask what others are doing next weekend or what happened in clinic earlier that day, or just to tell a good (clean) joke that is making the rounds. Conversely, if the case is complex, it often is best to wait until it is completed before asking questions.

8. When participating in a roundtable diagnosis, you are welcome to directly state the diagnosis for bread-and-butter cases, such as basal cell carcinomas and seborrheic keratoses. It is appropriate to be more descriptive and methodical in more complex cases. When evaluating a rash, give the general inflammatory pattern first. For example, is it spongiotic? Psoriasiform? Interface? Or a mixed pattern?

9. Extra points for identifying special sites! These include mucosal, genital, and acral sites. You might even get bonus points if you can determine something about the patient (child or adult) based on the pathologic features, such as variation in collagen patterns.

10. Whenever you are in doubt, just describe what you see. You can use the traditional top-down approach or start with stating the most evident finding, then proceed to a top-down description. If it is a neoplasm, describe the overall architecture; then, what you see at a cellular level will get you some points as well.

We acknowledge that this list of 10 tips is not comprehensive and might vary by attending and each institution’s distinctive training format. We are hopeful, however, that these 10 points of etiquette can serve as a guideline.

The Accreditation Council for Graduate Medical Education has established core competencies to serve as a foundation for the training received in a dermatology residency program.¹ Although programs are required to have the same concentrations—patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice—no specific guidelines are in place regarding how each of these competencies should be reached within a training period.² Instead, it remains the responsibility of each program to formulate an individualized curriculum to facilitate proficiency in the multiple areas encompassed by a residency.

In many dermatology residency programs, dermatopathology is a substantial component of educational objectives and the curriculum.¹ Residents may spend as much as 25% of their training on dermatopathology. However, there is great variability among programs in methods of teaching dermatopathology. When Hinshaw³ surveyed 52 of 109 dermatology residency programs, they identified differences in dermatopathology teaching that included, but was not limited to, utilization of problem-based learning (in 40.4% of programs), integration of journal reviews (53.8%), and computer-based learning (19.2%). In addition, differences were identified in the recommended primary textbook and the makeup of faculty who taught dermatopathology.³

Although residency programs vary in their methods of teaching this important component of dermatology, most use a multiheaded microscope in some capacity for didactics or sign-out. For most trainees, the dermatopathology laboratory is a new environment compared to the clinical space that medical students and residents become accustomed to throughout their education, thus creating a knowledge gap for trainees on proper dermatopathology etiquette and universal guidelines.

With medical students, residents, and fellows in mind, we have prepared a basic “dermatopathology etiquette” reference for trainees. Just as there are universal rules in the operating room for surgery (eg, sterile technique), we want to establish a code of conduct at the microscope. We hope that these 10 tips will, first, be useful to those who are unsure how to approach their first experience with dermatopathology and, second, serve as a guideline to aid development of appropriate communication skills and functioning within this novel setting. This list also can serve as a resource for dermatopathology attendings to provide to rotating residents and students.

1. New to pathology? It’s okay to ask. Do not hesitate to ask upper-year residents, fellows, and attendings for instructions on such matters as how to adjust your eyepiece to get the best resolution. 

2. If a slide drops on the floor, do not move! Your first instinct might be to move your chair to look for the dropped slide, but you might roll over it and break it.

3. When the attending is looking through the scope, you look through the scope. Dermatopathology is a visual exercise. Getting in your “optic mileage” is best done under the guidance of an experienced dermatopathologist.

4. Rules regarding food and drink at the microscope vary by pathologist. It’s best to ask what each attending prefers. Safe advice is to avoid foods that make noise, such as chewing gum and chips, and food that has a strong odor, such as microwaved leftovers.

5. Limit use of a laptop, cell phone, and smartwatch. If you think that using any of these is necessary, it generally is best to announce that you are looking up something related to the case and then share your findings (but not the most recent post on your Facebook News Feed).

6. If you notice that something needs correcting on the report, speak up! We are all human; we all make typos. Do not hesitate to mention this as soon as possible, especially before the case is signed out. You will likely be thanked by your attending because it is harder to rectify once the report has been signed out.

7. Small talk often is welcome during large excisions. This is a great time to ask what others are doing next weekend or what happened in clinic earlier that day, or just to tell a good (clean) joke that is making the rounds. Conversely, if the case is complex, it often is best to wait until it is completed before asking questions.

8. When participating in a roundtable diagnosis, you are welcome to directly state the diagnosis for bread-and-butter cases, such as basal cell carcinomas and seborrheic keratoses. It is appropriate to be more descriptive and methodical in more complex cases. When evaluating a rash, give the general inflammatory pattern first. For example, is it spongiotic? Psoriasiform? Interface? Or a mixed pattern?

9. Extra points for identifying special sites! These include mucosal, genital, and acral sites. You might even get bonus points if you can determine something about the patient (child or adult) based on the pathologic features, such as variation in collagen patterns.

10. Whenever you are in doubt, just describe what you see. You can use the traditional top-down approach or start with stating the most evident finding, then proceed to a top-down description. If it is a neoplasm, describe the overall architecture; then, what you see at a cellular level will get you some points as well.

We acknowledge that this list of 10 tips is not comprehensive and might vary by attending and each institution’s distinctive training format. We are hopeful, however, that these 10 points of etiquette can serve as a guideline.

As dermatology residents, we have a lot on our plates. With so many diagnoses to learn and treatments to understand, the sheer volume of knowledge we are expected to be familiar with sometimes can be overwhelming. The thought of adding yet another thing to the list of many things we already need to know—least of all a topic such as dermatoethics—may be unappealing. This article will discuss the importance of ethics training in dermatology residency as well as provide helpful resources for how this training can be achieved.

Professionalism as a Core Competency

The Accreditation Council for Graduate Medical Education (ACGME) considers professionalism as 1 of its 6 core competencies.¹ These competencies provide a conceptual framework detailing the domains physicians should be proficient in before they can enter autonomous practice. When it comes to professionalism, residents are expected to demonstrate compassion, integrity, and respect for others; honesty with patients; respect for patient confidentiality and autonomy; appropriate relationships with patients; accountability to patients, society, and the profession; and a sensitivity and responsiveness to diverse patient population.¹

The ACGME milestones are intended to assess resident development within the 6 competencies with more specific parameters for evaluation.² Those pertaining to professionalism evaluate a resident’s ability to demonstrate professional behavior, an understanding of ethical principles, accountability, and conscientiousness, as well as self-awareness and the ability to seek help for personal or professional well-being. The crux of the kinds of activities that constitute acquisition of these professional skills are specialty specific. The ACGME ultimately believes that having a working knowledge of professionalism and ethical principles prepares residents for practicing medicine in the real world. Because of these requirements, residency programs are expected to provide resources for residents to explore ethical problems faced by dermatologists.

Beyond “Passing” Residency

The reality is that learning about medical ethics and practicing professional behavior is not just about ticking boxes to get ACGME accreditation or to “pass” residency. The data suggest that having a strong foundation in these principles is good for overall personal well-being, job satisfaction, and patient care. Studies have shown that unprofessional behavior in medical school is correlated to disciplinary action by state licensing boards against practicing physicians.^3,4 In fact, a study found that in one cohort of physicians (N=68), 95% of disciplinary actions were for lapses in professionalism, which included activities such as sexual misconduct and inappropriate prescribing.⁴ Behaving appropriately protects your license to practice medicine.

Thinking through these problematic ethical scenarios also goes beyond coming up with the right answer. Exploring ethical conundrums is thought to develop analytical skills that can help one navigate future tricky situations that can be morally distressing and can lead to burnout. Introspection and self-awareness coupled with these skills ideally will help physicians think through sensitive and difficult situations with the courage to hold true to their convictions and ultimately uphold the professionalism of the specialty.⁵

Self-awareness has the additional bonus of empowering physicians to acknowledge personal and professional limitations with the goal of seeking help when it is needed before it is too late. It comes as no surprise that how we feel as physicians directly impacts how we treat our patients. One study found that depressed residents were more than 6 times more likely to make medication errors compared to nondepressed colleagues.⁶ Regularly taking stock of our professional and personal reserves can go a long way to improving overall well-being.

Resources for Dermatoethics Training

The best starting point for developing a robust dermatoethics curriculum is the material provided by the American Board of Dermatology, which is available online.⁷ An ad hoc subcommittee of the American Board of Dermatology composed of experts in dermatoethics and resident education reviewed relevant ethics literature and identified 6 core domains considered fundamental to dermatology resident education in ethics and professionalism.⁸ This team also provided a thorough list of relevant background readings for each topic. To cover pertinent material, the subcommittee recommended a 60-minute teaching session every other month with the intent of covering all the material over a 3-year period. If your program directors are not aware of this great resource and you feel your own ethics training may be lacking, bringing this up as a template might be helpful. A detailed description of an innovative dermatoethics curriculum organized at the Department of Dermatology at the Warren Alpert Medical School of Brown University (Providence, Rhode Island) in 2001 also may serve as a guide for programs hoping to design their own approach.⁵

For those interested in self-study, there is an excellent text dedicated to dermatoethics, which is aptly entitled Dermatoethics: Contemporary Ethics and Professionalism in Dermatology.⁹ This book offers superb case-based discussions on a wide range of ethical quandaries that dermatologists may face, ranging from unsolicited dermatologic advice (eg, Is it wrong to tell the person next to you in the grocery store that they might have a melanoma?) to research and publication ethics. This text provides a toolkit for handling tough situations in the clinic and beyond. The Journal of the American Academy of Dermatology publishes an Ethics Journal Club for which contributors can submit real-life practical ethical dilemmas, and the journal solicits a resolution or response from a dermatoethicist.

Additionally, a pilot curriculum project out of the University of Utah (Salt Lake City, Utah), of which I am a team member, currently is designing and testing several dermatoethics PowerPoint modules with the intention of making this material widely available through medical education portals.

The Hidden Curriculum

A formal curriculum can only provide so much when it comes to ethics training. In truth, much of what we learn as ethically minded dermatologists comes from our day-to-day practice.¹⁰ Paying attention to the more informal curriculum that we are immersed in during routine as well as unusual encounters also is important for achieving milestones. Teaching moments for thinking through ethical dilemmas abound, and this approach easily can be incorporated into routine workflow.¹¹ Next time you encounter an ethical situation that gives you pause (eg, Can I biopsy an intubated patient without getting appropriate consent?), talk it through with your supervisor. Gems of autonomous practice often can be mined from these off-the-cuff conversations.

Can Professionalism Be Taught?

Finally, it is worth mentioning that while the number of resources available to dermatology residents for honing their ethics skills is increasing, ways of measuring the impact of this additional training in vivo are not.¹² There are no good tools available to determine how ethics training influences resident behaviors. Similarly, there is no good evidence for what constitutes the most effective method for teaching medical ethics to trainees. It is a growing field with lots of room for more robust research. For now, the overall goal of a dermatoethics curriculum is to provide a mix of curriculum opportunities, ranging from formal lectures and readings to more informal conversations, with the hope of providing residents a toolbox for dealing with ethical dilemmas and a working knowledge of professionalism.

Final Thoughts

There are several resources available for dermatology programs to provide quality dermatoethics training to their residents. These can be mixed and matched to create a tailored formal curriculum alongside the more informal ethics training that happens in the clinic and on the wards. Providing this education is about more than just fulfilling accreditation requirements. Understanding ethical principles and how they can be applied to navigate sensitive situations is ultimately good for both professional and personal well-being.

As dermatology residents, we have a lot on our plates. With so many diagnoses to learn and treatments to understand, the sheer volume of knowledge we are expected to be familiar with sometimes can be overwhelming. The thought of adding yet another thing to the list of many things we already need to know—least of all a topic such as dermatoethics—may be unappealing. This article will discuss the importance of ethics training in dermatology residency as well as provide helpful resources for how this training can be achieved.

Professionalism as a Core Competency

The Accreditation Council for Graduate Medical Education (ACGME) considers professionalism as 1 of its 6 core competencies.¹ These competencies provide a conceptual framework detailing the domains physicians should be proficient in before they can enter autonomous practice. When it comes to professionalism, residents are expected to demonstrate compassion, integrity, and respect for others; honesty with patients; respect for patient confidentiality and autonomy; appropriate relationships with patients; accountability to patients, society, and the profession; and a sensitivity and responsiveness to diverse patient population.¹

The ACGME milestones are intended to assess resident development within the 6 competencies with more specific parameters for evaluation.² Those pertaining to professionalism evaluate a resident’s ability to demonstrate professional behavior, an understanding of ethical principles, accountability, and conscientiousness, as well as self-awareness and the ability to seek help for personal or professional well-being. The crux of the kinds of activities that constitute acquisition of these professional skills are specialty specific. The ACGME ultimately believes that having a working knowledge of professionalism and ethical principles prepares residents for practicing medicine in the real world. Because of these requirements, residency programs are expected to provide resources for residents to explore ethical problems faced by dermatologists.

Beyond “Passing” Residency

The reality is that learning about medical ethics and practicing professional behavior is not just about ticking boxes to get ACGME accreditation or to “pass” residency. The data suggest that having a strong foundation in these principles is good for overall personal well-being, job satisfaction, and patient care. Studies have shown that unprofessional behavior in medical school is correlated to disciplinary action by state licensing boards against practicing physicians.^3,4 In fact, a study found that in one cohort of physicians (N=68), 95% of disciplinary actions were for lapses in professionalism, which included activities such as sexual misconduct and inappropriate prescribing.⁴ Behaving appropriately protects your license to practice medicine.

Thinking through these problematic ethical scenarios also goes beyond coming up with the right answer. Exploring ethical conundrums is thought to develop analytical skills that can help one navigate future tricky situations that can be morally distressing and can lead to burnout. Introspection and self-awareness coupled with these skills ideally will help physicians think through sensitive and difficult situations with the courage to hold true to their convictions and ultimately uphold the professionalism of the specialty.⁵

Self-awareness has the additional bonus of empowering physicians to acknowledge personal and professional limitations with the goal of seeking help when it is needed before it is too late. It comes as no surprise that how we feel as physicians directly impacts how we treat our patients. One study found that depressed residents were more than 6 times more likely to make medication errors compared to nondepressed colleagues.⁶ Regularly taking stock of our professional and personal reserves can go a long way to improving overall well-being.

Resources for Dermatoethics Training

The best starting point for developing a robust dermatoethics curriculum is the material provided by the American Board of Dermatology, which is available online.⁷ An ad hoc subcommittee of the American Board of Dermatology composed of experts in dermatoethics and resident education reviewed relevant ethics literature and identified 6 core domains considered fundamental to dermatology resident education in ethics and professionalism.⁸ This team also provided a thorough list of relevant background readings for each topic. To cover pertinent material, the subcommittee recommended a 60-minute teaching session every other month with the intent of covering all the material over a 3-year period. If your program directors are not aware of this great resource and you feel your own ethics training may be lacking, bringing this up as a template might be helpful. A detailed description of an innovative dermatoethics curriculum organized at the Department of Dermatology at the Warren Alpert Medical School of Brown University (Providence, Rhode Island) in 2001 also may serve as a guide for programs hoping to design their own approach.⁵

For those interested in self-study, there is an excellent text dedicated to dermatoethics, which is aptly entitled Dermatoethics: Contemporary Ethics and Professionalism in Dermatology.⁹ This book offers superb case-based discussions on a wide range of ethical quandaries that dermatologists may face, ranging from unsolicited dermatologic advice (eg, Is it wrong to tell the person next to you in the grocery store that they might have a melanoma?) to research and publication ethics. This text provides a toolkit for handling tough situations in the clinic and beyond. The Journal of the American Academy of Dermatology publishes an Ethics Journal Club for which contributors can submit real-life practical ethical dilemmas, and the journal solicits a resolution or response from a dermatoethicist.

Additionally, a pilot curriculum project out of the University of Utah (Salt Lake City, Utah), of which I am a team member, currently is designing and testing several dermatoethics PowerPoint modules with the intention of making this material widely available through medical education portals.

The Hidden Curriculum

A formal curriculum can only provide so much when it comes to ethics training. In truth, much of what we learn as ethically minded dermatologists comes from our day-to-day practice.¹⁰ Paying attention to the more informal curriculum that we are immersed in during routine as well as unusual encounters also is important for achieving milestones. Teaching moments for thinking through ethical dilemmas abound, and this approach easily can be incorporated into routine workflow.¹¹ Next time you encounter an ethical situation that gives you pause (eg, Can I biopsy an intubated patient without getting appropriate consent?), talk it through with your supervisor. Gems of autonomous practice often can be mined from these off-the-cuff conversations.

Can Professionalism Be Taught?

Finally, it is worth mentioning that while the number of resources available to dermatology residents for honing their ethics skills is increasing, ways of measuring the impact of this additional training in vivo are not.¹² There are no good tools available to determine how ethics training influences resident behaviors. Similarly, there is no good evidence for what constitutes the most effective method for teaching medical ethics to trainees. It is a growing field with lots of room for more robust research. For now, the overall goal of a dermatoethics curriculum is to provide a mix of curriculum opportunities, ranging from formal lectures and readings to more informal conversations, with the hope of providing residents a toolbox for dealing with ethical dilemmas and a working knowledge of professionalism.

Final Thoughts

There are several resources available for dermatology programs to provide quality dermatoethics training to their residents. These can be mixed and matched to create a tailored formal curriculum alongside the more informal ethics training that happens in the clinic and on the wards. Providing this education is about more than just fulfilling accreditation requirements. Understanding ethical principles and how they can be applied to navigate sensitive situations is ultimately good for both professional and personal well-being.

As dermatology residents, we have a lot on our plates. With so many diagnoses to learn and treatments to understand, the sheer volume of knowledge we are expected to be familiar with sometimes can be overwhelming. The thought of adding yet another thing to the list of many things we already need to know—least of all a topic such as dermatoethics—may be unappealing. This article will discuss the importance of ethics training in dermatology residency as well as provide helpful resources for how this training can be achieved.

Professionalism as a Core Competency

The Accreditation Council for Graduate Medical Education (ACGME) considers professionalism as 1 of its 6 core competencies.¹ These competencies provide a conceptual framework detailing the domains physicians should be proficient in before they can enter autonomous practice. When it comes to professionalism, residents are expected to demonstrate compassion, integrity, and respect for others; honesty with patients; respect for patient confidentiality and autonomy; appropriate relationships with patients; accountability to patients, society, and the profession; and a sensitivity and responsiveness to diverse patient population.¹

The ACGME milestones are intended to assess resident development within the 6 competencies with more specific parameters for evaluation.² Those pertaining to professionalism evaluate a resident’s ability to demonstrate professional behavior, an understanding of ethical principles, accountability, and conscientiousness, as well as self-awareness and the ability to seek help for personal or professional well-being. The crux of the kinds of activities that constitute acquisition of these professional skills are specialty specific. The ACGME ultimately believes that having a working knowledge of professionalism and ethical principles prepares residents for practicing medicine in the real world. Because of these requirements, residency programs are expected to provide resources for residents to explore ethical problems faced by dermatologists.

Beyond “Passing” Residency

The reality is that learning about medical ethics and practicing professional behavior is not just about ticking boxes to get ACGME accreditation or to “pass” residency. The data suggest that having a strong foundation in these principles is good for overall personal well-being, job satisfaction, and patient care. Studies have shown that unprofessional behavior in medical school is correlated to disciplinary action by state licensing boards against practicing physicians.^3,4 In fact, a study found that in one cohort of physicians (N=68), 95% of disciplinary actions were for lapses in professionalism, which included activities such as sexual misconduct and inappropriate prescribing.⁴ Behaving appropriately protects your license to practice medicine.

Thinking through these problematic ethical scenarios also goes beyond coming up with the right answer. Exploring ethical conundrums is thought to develop analytical skills that can help one navigate future tricky situations that can be morally distressing and can lead to burnout. Introspection and self-awareness coupled with these skills ideally will help physicians think through sensitive and difficult situations with the courage to hold true to their convictions and ultimately uphold the professionalism of the specialty.⁵

Self-awareness has the additional bonus of empowering physicians to acknowledge personal and professional limitations with the goal of seeking help when it is needed before it is too late. It comes as no surprise that how we feel as physicians directly impacts how we treat our patients. One study found that depressed residents were more than 6 times more likely to make medication errors compared to nondepressed colleagues.⁶ Regularly taking stock of our professional and personal reserves can go a long way to improving overall well-being.

Resources for Dermatoethics Training

The best starting point for developing a robust dermatoethics curriculum is the material provided by the American Board of Dermatology, which is available online.⁷ An ad hoc subcommittee of the American Board of Dermatology composed of experts in dermatoethics and resident education reviewed relevant ethics literature and identified 6 core domains considered fundamental to dermatology resident education in ethics and professionalism.⁸ This team also provided a thorough list of relevant background readings for each topic. To cover pertinent material, the subcommittee recommended a 60-minute teaching session every other month with the intent of covering all the material over a 3-year period. If your program directors are not aware of this great resource and you feel your own ethics training may be lacking, bringing this up as a template might be helpful. A detailed description of an innovative dermatoethics curriculum organized at the Department of Dermatology at the Warren Alpert Medical School of Brown University (Providence, Rhode Island) in 2001 also may serve as a guide for programs hoping to design their own approach.⁵

For those interested in self-study, there is an excellent text dedicated to dermatoethics, which is aptly entitled Dermatoethics: Contemporary Ethics and Professionalism in Dermatology.⁹ This book offers superb case-based discussions on a wide range of ethical quandaries that dermatologists may face, ranging from unsolicited dermatologic advice (eg, Is it wrong to tell the person next to you in the grocery store that they might have a melanoma?) to research and publication ethics. This text provides a toolkit for handling tough situations in the clinic and beyond. The Journal of the American Academy of Dermatology publishes an Ethics Journal Club for which contributors can submit real-life practical ethical dilemmas, and the journal solicits a resolution or response from a dermatoethicist.

Additionally, a pilot curriculum project out of the University of Utah (Salt Lake City, Utah), of which I am a team member, currently is designing and testing several dermatoethics PowerPoint modules with the intention of making this material widely available through medical education portals.

The Hidden Curriculum

A formal curriculum can only provide so much when it comes to ethics training. In truth, much of what we learn as ethically minded dermatologists comes from our day-to-day practice.¹⁰ Paying attention to the more informal curriculum that we are immersed in during routine as well as unusual encounters also is important for achieving milestones. Teaching moments for thinking through ethical dilemmas abound, and this approach easily can be incorporated into routine workflow.¹¹ Next time you encounter an ethical situation that gives you pause (eg, Can I biopsy an intubated patient without getting appropriate consent?), talk it through with your supervisor. Gems of autonomous practice often can be mined from these off-the-cuff conversations.

Can Professionalism Be Taught?

Finally, it is worth mentioning that while the number of resources available to dermatology residents for honing their ethics skills is increasing, ways of measuring the impact of this additional training in vivo are not.¹² There are no good tools available to determine how ethics training influences resident behaviors. Similarly, there is no good evidence for what constitutes the most effective method for teaching medical ethics to trainees. It is a growing field with lots of room for more robust research. For now, the overall goal of a dermatoethics curriculum is to provide a mix of curriculum opportunities, ranging from formal lectures and readings to more informal conversations, with the hope of providing residents a toolbox for dealing with ethical dilemmas and a working knowledge of professionalism.

Final Thoughts

There are several resources available for dermatology programs to provide quality dermatoethics training to their residents. These can be mixed and matched to create a tailored formal curriculum alongside the more informal ethics training that happens in the clinic and on the wards. Providing this education is about more than just fulfilling accreditation requirements. Understanding ethical principles and how they can be applied to navigate sensitive situations is ultimately good for both professional and personal well-being.

To the Editor:

With a trend toward increasing pass/fail medical school curricula, residency program directors (PDs) have relied on the US Medical Licensing Examination (USMLE) Step 1 as an objective measurement of applicant achievement, which is particularly true in competitive subspecialties such as dermatology, plastic surgery, orthopedic surgery, ophthalmology, and neurosurgery, in which reported Step 1 scores are consistently the highest among matched applicants.¹ Program directors in dermatology have indicated that Step 1 scores are a priority when considering an applicant.² However, among PDs, the general perception of plans to change Step 1 scores to pass/fail has largely been negative.³ Although the impact of this change on the dermatology residency selection process remains unknown, we undertook a study to determine dermatology PDs’ perspectives on the scoring change and discuss its potential implications among all competitive specialties.

A 19-question survey was designed that assessed PD demographics and opinions of the changes and potential implications of the Step 1 scoring change (eTable). A list of current US dermatology PDs at osteopathic and allopathic programs was obtained through the 2019-2020 Accreditation Council for Graduate Medical Education list of accredited programs. Surveys were piloted at our institution to assess for internal validity and misleading questions, and then were distributed electronically through REDCap software (https://www.project-redcap.org/). All responses were kept anonymous. Institutional review board approval was obtained. Variables were assessed with means, proportions, and CIs. Results were deemed statistically significant with nonoverlapping 99% CIs (P<.01).

In dermatology and other competitive specialties, in which USMLE Step 1 scores have become an important consideration, PDs and residency programs will need to identify additional metrics to compare applicants. Examples include research productivity, grades on relevant rotations, and shelf examination scores. Although more reliable subjective measures, such as interviews and performance on away rotations, are already important, they may become of greater significance.

The findings of our survey suggest that PDs are skeptical about changes to Step 1 and more diligence is necessary to maintain a fair and impartial selection process. Increased emphasis on other objective measurements, such as shelf examination scores, graded curricular components, and research productivity, could help maintain an unbiased approach. With changes to USMLE Step 1 expected to be implemented in the 2022 application cycle, programs may need to explore additional options to maintain reliable and transparent applicant review practices.

To the Editor:

With a trend toward increasing pass/fail medical school curricula, residency program directors (PDs) have relied on the US Medical Licensing Examination (USMLE) Step 1 as an objective measurement of applicant achievement, which is particularly true in competitive subspecialties such as dermatology, plastic surgery, orthopedic surgery, ophthalmology, and neurosurgery, in which reported Step 1 scores are consistently the highest among matched applicants.¹ Program directors in dermatology have indicated that Step 1 scores are a priority when considering an applicant.² However, among PDs, the general perception of plans to change Step 1 scores to pass/fail has largely been negative.³ Although the impact of this change on the dermatology residency selection process remains unknown, we undertook a study to determine dermatology PDs’ perspectives on the scoring change and discuss its potential implications among all competitive specialties.

A 19-question survey was designed that assessed PD demographics and opinions of the changes and potential implications of the Step 1 scoring change (eTable). A list of current US dermatology PDs at osteopathic and allopathic programs was obtained through the 2019-2020 Accreditation Council for Graduate Medical Education list of accredited programs. Surveys were piloted at our institution to assess for internal validity and misleading questions, and then were distributed electronically through REDCap software (https://www.project-redcap.org/). All responses were kept anonymous. Institutional review board approval was obtained. Variables were assessed with means, proportions, and CIs. Results were deemed statistically significant with nonoverlapping 99% CIs (P<.01).

In dermatology and other competitive specialties, in which USMLE Step 1 scores have become an important consideration, PDs and residency programs will need to identify additional metrics to compare applicants. Examples include research productivity, grades on relevant rotations, and shelf examination scores. Although more reliable subjective measures, such as interviews and performance on away rotations, are already important, they may become of greater significance.

The findings of our survey suggest that PDs are skeptical about changes to Step 1 and more diligence is necessary to maintain a fair and impartial selection process. Increased emphasis on other objective measurements, such as shelf examination scores, graded curricular components, and research productivity, could help maintain an unbiased approach. With changes to USMLE Step 1 expected to be implemented in the 2022 application cycle, programs may need to explore additional options to maintain reliable and transparent applicant review practices.

To the Editor:

With a trend toward increasing pass/fail medical school curricula, residency program directors (PDs) have relied on the US Medical Licensing Examination (USMLE) Step 1 as an objective measurement of applicant achievement, which is particularly true in competitive subspecialties such as dermatology, plastic surgery, orthopedic surgery, ophthalmology, and neurosurgery, in which reported Step 1 scores are consistently the highest among matched applicants.¹ Program directors in dermatology have indicated that Step 1 scores are a priority when considering an applicant.² However, among PDs, the general perception of plans to change Step 1 scores to pass/fail has largely been negative.³ Although the impact of this change on the dermatology residency selection process remains unknown, we undertook a study to determine dermatology PDs’ perspectives on the scoring change and discuss its potential implications among all competitive specialties.

A 19-question survey was designed that assessed PD demographics and opinions of the changes and potential implications of the Step 1 scoring change (eTable). A list of current US dermatology PDs at osteopathic and allopathic programs was obtained through the 2019-2020 Accreditation Council for Graduate Medical Education list of accredited programs. Surveys were piloted at our institution to assess for internal validity and misleading questions, and then were distributed electronically through REDCap software (https://www.project-redcap.org/). All responses were kept anonymous. Institutional review board approval was obtained. Variables were assessed with means, proportions, and CIs. Results were deemed statistically significant with nonoverlapping 99% CIs (P<.01).

In dermatology and other competitive specialties, in which USMLE Step 1 scores have become an important consideration, PDs and residency programs will need to identify additional metrics to compare applicants. Examples include research productivity, grades on relevant rotations, and shelf examination scores. Although more reliable subjective measures, such as interviews and performance on away rotations, are already important, they may become of greater significance.

The findings of our survey suggest that PDs are skeptical about changes to Step 1 and more diligence is necessary to maintain a fair and impartial selection process. Increased emphasis on other objective measurements, such as shelf examination scores, graded curricular components, and research productivity, could help maintain an unbiased approach. With changes to USMLE Step 1 expected to be implemented in the 2022 application cycle, programs may need to explore additional options to maintain reliable and transparent applicant review practices.

Applications of 3-dimensional (3D) printing in medical imaging and health care are expanding. 3D printing may serve a variety of roles and is used increasingly in the context of presurgical planning, as specific medical models may be created using individual patient imaging data.¹ These patient-specific models may assist in medical trainee education, decrease operating room time, improve patient education for potential planned surgery, and guide clinicians for optimizing therapy.^1,2 This article discusses the utility of 3D printing at a single institution to serve in enhancing specifically neuroradiology education.

Background

As digital imaging and 3D printing have increased in popularity, the potential application of using imaging data to guide patient therapy has shown significant promise. Computed tomography (CT) is a commonly used modality that can be used to create 3D anatomical models, as it is frequently used in the medical setting, demonstrates excellent resolution to the millimeter scale, and can readily pinpoint pathology on imaging.

Image Acquisition

CT scans can be rapidly obtained, which adds significant value, particularly in the context of point-of-care 3D printing. Another modality commonly used for 3D printing is magnetic resonance imaging (MRI), which unlike CT, does not expose the patient to ionizing radiation. The 3D printing process is initiated with patient-specific CT or MRI data stored in the digital imaging and communications in medicine (DICOM) format, which is the international standard for communication and management of medical imaging information and related data. DICOM allows for faster and robust collaboration among imaging professionals.³

Image Processing 

To print 3D anatomical models, patient-specific data must be converted from DICOM into standard tessellation language (STL) format, which can be created and edited with a variety of softwares.³ At James A. Haley Veterans’ Hospital in Tampa, Florida, we use an image processing package that includes the Materialise 3-matic and interactive medical image control system. Image quality is essential; therefore, careful attention to details such as pixel dimensions, slice thickness, and slice increments must be considered.^3,4

An STL file creates a 3D image from triangle approximations. The entire 3D shape will be made of numerous large or small triangles, depending on the slice thickness, therefore, quality of the original radiologic image. The size and position of the triangles used to make the model can be varied to approximate the object’s shape. The smaller the triangles, the better the image quality and vice versa. This concept is analogous to approximating a circle using straight lines of equal length—more, smaller lines will result in better approximation of a circle (Figure 1).^5,6 Similarly, using smaller triangles allows for better approximation of the image. As the human body is a complex structure, mimicking the body requires a system able to create nongeometrical shapes, which is made possible via these triangle approximations in a 3D STL file.

The creation of an STL file from DICOM data starts with a threshold-based segmentation process followed by additional fine-tuning and edits, and ends in the creation of a 3D part. The initial segmentation can be created with the threshold tool, using a Hounsfield unit range based on the area of interest desired (eg, bone, blood, fat). This is used to create an initial mask, which can be further optimized. The region grow tool allows the user to focus the segmentation by discarding areas that are not directly connected to the region of interest. In contrast, the split mask tool divides areas that are connected. Next, fine-tuning the segmentation using tools such as multiple slice edit helps to optimize the model. After all edits are made, the calculate part tool converts the mask into a 3D component that can be used in downstream applications. For the purposes of demonstration and proof of concept, the models provided in this article were created via open-source hardware designs under free or open licenses.^7-9

3D Printing in Neuroradiology Education

Neuroradiologists focus on diagnosing pathology related to the brain, head and neck, and spine. CT and MRI scans are the primary modalities used to diagnose these conditions. 3D printing is a useful tool for the trainee who wishes to fully understand neuroanatomy and obtain further appreciation of imaging pathology as it relates to 3D anatomy. Head and neck imaging are a complex subdiscipline of neuroradiology that often require further training beyond radiology residency. A neuroradiology fellowship that focuses on head and neck imaging extends the training.

3D printing has the potential to improve the understanding of various imaging pathologies by providing the trainee with a more in-depth appreciation of the anterior, middle, and posterior cranial fossa, the skull base foramina (ie, foramen ovale, spinosum, rotundum), and complex 3D areas, such as the pterygopalatine fossa, which are all critical areas to investigate on imaging. Figure 2 highlights how a complex anatomical structure, such as the sphenoid bone when printed in 3D, can be correlated with CT cross-sectional images to supplement the educational experience.

Future Directions

Artificial Intelligence (AI) offers the ability to teach computers to perform tasks that ordinarily require human intelligence. In the context of 3D printing, the ability to use AI to readily convert and process DICOM data into printable STL models holds significant promise. Currently, the manual conversion of a DICOM file into a segmented 3D model may take several days, necessitating a number of productive hours even from the imaging and engineering champion. If machines could aid in this process, the ability to readily scale clinical 3D printing and promote widespread adoption would be feasible. Several studies already are looking into this concept to determine how deep learning networks may automatically recognize lesions on medical imaging to assist a human operator, potentially cutting hours from the clinical 3D printing workflow.^12,13

Furthermore, there are several applications for AI in the context of 3D printing upstream or before the creation of a 3D model. A number of AI tools are already in use at the CT and MRI scanner. Current strategies leverage deep learning and advances in neural networks to improve image quality and create thin section DICOM data, which can be converted into printable 3D files. Additionally, the ability to automate tasks using AI can improve production capacity by assessing material costs and ensuring cost efficiency, which will be critical as point-of-care 3D printing develops widespread adoption. AI also can reduce printing errors by using automated adaptive feedback, using machine learning to search for possible print errors, and sending feedback to the computer to ensure appropriate settings (eg, temperature settings/environmental conditions).

Conclusions

Based on this single-institution experience, 3D-printed complex neuroanatomical structures seems feasible and may enhance resident education and patient safety. Interested trainees may have the opportunity to learn and be involved in the printing process of new and innovative ideas. Further studies may involve printing various pathologic processes and applying these same steps and principles to other subspecialties of radiology. Finally, AI has the potential to advance the 3D printing process in the future.

Applications of 3-dimensional (3D) printing in medical imaging and health care are expanding. 3D printing may serve a variety of roles and is used increasingly in the context of presurgical planning, as specific medical models may be created using individual patient imaging data.¹ These patient-specific models may assist in medical trainee education, decrease operating room time, improve patient education for potential planned surgery, and guide clinicians for optimizing therapy.^1,2 This article discusses the utility of 3D printing at a single institution to serve in enhancing specifically neuroradiology education.

Background

As digital imaging and 3D printing have increased in popularity, the potential application of using imaging data to guide patient therapy has shown significant promise. Computed tomography (CT) is a commonly used modality that can be used to create 3D anatomical models, as it is frequently used in the medical setting, demonstrates excellent resolution to the millimeter scale, and can readily pinpoint pathology on imaging.

Image Acquisition

CT scans can be rapidly obtained, which adds significant value, particularly in the context of point-of-care 3D printing. Another modality commonly used for 3D printing is magnetic resonance imaging (MRI), which unlike CT, does not expose the patient to ionizing radiation. The 3D printing process is initiated with patient-specific CT or MRI data stored in the digital imaging and communications in medicine (DICOM) format, which is the international standard for communication and management of medical imaging information and related data. DICOM allows for faster and robust collaboration among imaging professionals.³

Image Processing 

To print 3D anatomical models, patient-specific data must be converted from DICOM into standard tessellation language (STL) format, which can be created and edited with a variety of softwares.³ At James A. Haley Veterans’ Hospital in Tampa, Florida, we use an image processing package that includes the Materialise 3-matic and interactive medical image control system. Image quality is essential; therefore, careful attention to details such as pixel dimensions, slice thickness, and slice increments must be considered.^3,4

An STL file creates a 3D image from triangle approximations. The entire 3D shape will be made of numerous large or small triangles, depending on the slice thickness, therefore, quality of the original radiologic image. The size and position of the triangles used to make the model can be varied to approximate the object’s shape. The smaller the triangles, the better the image quality and vice versa. This concept is analogous to approximating a circle using straight lines of equal length—more, smaller lines will result in better approximation of a circle (Figure 1).^5,6 Similarly, using smaller triangles allows for better approximation of the image. As the human body is a complex structure, mimicking the body requires a system able to create nongeometrical shapes, which is made possible via these triangle approximations in a 3D STL file.

The creation of an STL file from DICOM data starts with a threshold-based segmentation process followed by additional fine-tuning and edits, and ends in the creation of a 3D part. The initial segmentation can be created with the threshold tool, using a Hounsfield unit range based on the area of interest desired (eg, bone, blood, fat). This is used to create an initial mask, which can be further optimized. The region grow tool allows the user to focus the segmentation by discarding areas that are not directly connected to the region of interest. In contrast, the split mask tool divides areas that are connected. Next, fine-tuning the segmentation using tools such as multiple slice edit helps to optimize the model. After all edits are made, the calculate part tool converts the mask into a 3D component that can be used in downstream applications. For the purposes of demonstration and proof of concept, the models provided in this article were created via open-source hardware designs under free or open licenses.^7-9

3D Printing in Neuroradiology Education

Neuroradiologists focus on diagnosing pathology related to the brain, head and neck, and spine. CT and MRI scans are the primary modalities used to diagnose these conditions. 3D printing is a useful tool for the trainee who wishes to fully understand neuroanatomy and obtain further appreciation of imaging pathology as it relates to 3D anatomy. Head and neck imaging are a complex subdiscipline of neuroradiology that often require further training beyond radiology residency. A neuroradiology fellowship that focuses on head and neck imaging extends the training.

3D printing has the potential to improve the understanding of various imaging pathologies by providing the trainee with a more in-depth appreciation of the anterior, middle, and posterior cranial fossa, the skull base foramina (ie, foramen ovale, spinosum, rotundum), and complex 3D areas, such as the pterygopalatine fossa, which are all critical areas to investigate on imaging. Figure 2 highlights how a complex anatomical structure, such as the sphenoid bone when printed in 3D, can be correlated with CT cross-sectional images to supplement the educational experience.

Future Directions

Artificial Intelligence (AI) offers the ability to teach computers to perform tasks that ordinarily require human intelligence. In the context of 3D printing, the ability to use AI to readily convert and process DICOM data into printable STL models holds significant promise. Currently, the manual conversion of a DICOM file into a segmented 3D model may take several days, necessitating a number of productive hours even from the imaging and engineering champion. If machines could aid in this process, the ability to readily scale clinical 3D printing and promote widespread adoption would be feasible. Several studies already are looking into this concept to determine how deep learning networks may automatically recognize lesions on medical imaging to assist a human operator, potentially cutting hours from the clinical 3D printing workflow.^12,13

Furthermore, there are several applications for AI in the context of 3D printing upstream or before the creation of a 3D model. A number of AI tools are already in use at the CT and MRI scanner. Current strategies leverage deep learning and advances in neural networks to improve image quality and create thin section DICOM data, which can be converted into printable 3D files. Additionally, the ability to automate tasks using AI can improve production capacity by assessing material costs and ensuring cost efficiency, which will be critical as point-of-care 3D printing develops widespread adoption. AI also can reduce printing errors by using automated adaptive feedback, using machine learning to search for possible print errors, and sending feedback to the computer to ensure appropriate settings (eg, temperature settings/environmental conditions).

Conclusions

Based on this single-institution experience, 3D-printed complex neuroanatomical structures seems feasible and may enhance resident education and patient safety. Interested trainees may have the opportunity to learn and be involved in the printing process of new and innovative ideas. Further studies may involve printing various pathologic processes and applying these same steps and principles to other subspecialties of radiology. Finally, AI has the potential to advance the 3D printing process in the future.

Applications of 3-dimensional (3D) printing in medical imaging and health care are expanding. 3D printing may serve a variety of roles and is used increasingly in the context of presurgical planning, as specific medical models may be created using individual patient imaging data.¹ These patient-specific models may assist in medical trainee education, decrease operating room time, improve patient education for potential planned surgery, and guide clinicians for optimizing therapy.^1,2 This article discusses the utility of 3D printing at a single institution to serve in enhancing specifically neuroradiology education.

Background

As digital imaging and 3D printing have increased in popularity, the potential application of using imaging data to guide patient therapy has shown significant promise. Computed tomography (CT) is a commonly used modality that can be used to create 3D anatomical models, as it is frequently used in the medical setting, demonstrates excellent resolution to the millimeter scale, and can readily pinpoint pathology on imaging.

Image Acquisition

CT scans can be rapidly obtained, which adds significant value, particularly in the context of point-of-care 3D printing. Another modality commonly used for 3D printing is magnetic resonance imaging (MRI), which unlike CT, does not expose the patient to ionizing radiation. The 3D printing process is initiated with patient-specific CT or MRI data stored in the digital imaging and communications in medicine (DICOM) format, which is the international standard for communication and management of medical imaging information and related data. DICOM allows for faster and robust collaboration among imaging professionals.³

Image Processing 

To print 3D anatomical models, patient-specific data must be converted from DICOM into standard tessellation language (STL) format, which can be created and edited with a variety of softwares.³ At James A. Haley Veterans’ Hospital in Tampa, Florida, we use an image processing package that includes the Materialise 3-matic and interactive medical image control system. Image quality is essential; therefore, careful attention to details such as pixel dimensions, slice thickness, and slice increments must be considered.^3,4

An STL file creates a 3D image from triangle approximations. The entire 3D shape will be made of numerous large or small triangles, depending on the slice thickness, therefore, quality of the original radiologic image. The size and position of the triangles used to make the model can be varied to approximate the object’s shape. The smaller the triangles, the better the image quality and vice versa. This concept is analogous to approximating a circle using straight lines of equal length—more, smaller lines will result in better approximation of a circle (Figure 1).^5,6 Similarly, using smaller triangles allows for better approximation of the image. As the human body is a complex structure, mimicking the body requires a system able to create nongeometrical shapes, which is made possible via these triangle approximations in a 3D STL file.

The creation of an STL file from DICOM data starts with a threshold-based segmentation process followed by additional fine-tuning and edits, and ends in the creation of a 3D part. The initial segmentation can be created with the threshold tool, using a Hounsfield unit range based on the area of interest desired (eg, bone, blood, fat). This is used to create an initial mask, which can be further optimized. The region grow tool allows the user to focus the segmentation by discarding areas that are not directly connected to the region of interest. In contrast, the split mask tool divides areas that are connected. Next, fine-tuning the segmentation using tools such as multiple slice edit helps to optimize the model. After all edits are made, the calculate part tool converts the mask into a 3D component that can be used in downstream applications. For the purposes of demonstration and proof of concept, the models provided in this article were created via open-source hardware designs under free or open licenses.^7-9

3D Printing in Neuroradiology Education

Neuroradiologists focus on diagnosing pathology related to the brain, head and neck, and spine. CT and MRI scans are the primary modalities used to diagnose these conditions. 3D printing is a useful tool for the trainee who wishes to fully understand neuroanatomy and obtain further appreciation of imaging pathology as it relates to 3D anatomy. Head and neck imaging are a complex subdiscipline of neuroradiology that often require further training beyond radiology residency. A neuroradiology fellowship that focuses on head and neck imaging extends the training.

3D printing has the potential to improve the understanding of various imaging pathologies by providing the trainee with a more in-depth appreciation of the anterior, middle, and posterior cranial fossa, the skull base foramina (ie, foramen ovale, spinosum, rotundum), and complex 3D areas, such as the pterygopalatine fossa, which are all critical areas to investigate on imaging. Figure 2 highlights how a complex anatomical structure, such as the sphenoid bone when printed in 3D, can be correlated with CT cross-sectional images to supplement the educational experience.

Future Directions

Artificial Intelligence (AI) offers the ability to teach computers to perform tasks that ordinarily require human intelligence. In the context of 3D printing, the ability to use AI to readily convert and process DICOM data into printable STL models holds significant promise. Currently, the manual conversion of a DICOM file into a segmented 3D model may take several days, necessitating a number of productive hours even from the imaging and engineering champion. If machines could aid in this process, the ability to readily scale clinical 3D printing and promote widespread adoption would be feasible. Several studies already are looking into this concept to determine how deep learning networks may automatically recognize lesions on medical imaging to assist a human operator, potentially cutting hours from the clinical 3D printing workflow.^12,13

Furthermore, there are several applications for AI in the context of 3D printing upstream or before the creation of a 3D model. A number of AI tools are already in use at the CT and MRI scanner. Current strategies leverage deep learning and advances in neural networks to improve image quality and create thin section DICOM data, which can be converted into printable 3D files. Additionally, the ability to automate tasks using AI can improve production capacity by assessing material costs and ensuring cost efficiency, which will be critical as point-of-care 3D printing develops widespread adoption. AI also can reduce printing errors by using automated adaptive feedback, using machine learning to search for possible print errors, and sending feedback to the computer to ensure appropriate settings (eg, temperature settings/environmental conditions).

Conclusions

Based on this single-institution experience, 3D-printed complex neuroanatomical structures seems feasible and may enhance resident education and patient safety. Interested trainees may have the opportunity to learn and be involved in the printing process of new and innovative ideas. Further studies may involve printing various pathologic processes and applying these same steps and principles to other subspecialties of radiology. Finally, AI has the potential to advance the 3D printing process in the future.

Multidisciplinary tumor boards are composed of providers from many fields who deliver coordinated care for patients with unresectable and high-risk skin cancers. Providers who comprise the tumor board often are radiation oncologists, hematologists/oncologists, general surgeons, dermatologists, dermatologic surgeons, and pathologists. The benefit of having a tumor board is that each patient is evaluated simultaneously by a group of physicians from various specialties who bring diverse perspectives that will contribute to the overall treatment plan. The cases often encompass high-risk tumors including unresectable basal cell carcinomas or invasive melanomas. By combining knowledge from each specialty in a team approach, the tumor board can effectively and holistically develop a care plan for each patient.

For the tumor board at the Warren Alpert Medical School of Brown University (Providence, Rhode Island), we often prepare a presentation with comprehensive details about the patient and tumor. During the presentation, we also propose a treatment plan prior to describing each patient at the weekly conference and amend the plans during the discussion. Tumor boards also provide a consulting role to the community and hospital providers in which patients are being referred by their primary provider and are seeking a second opinion or guidance.

In many ways, the tumor board is a multidisciplinary approach for patient advocacy in the form of treatment. These physicians meet on a regular basis to check on the patient’s progress and continually reevaluate how to have discussions about the patient’s care. There are many reasons why it is important to refer patients to a multidisciplinary tumor board.

Improved Workup and Diagnosis

One of the values of a tumor board is that it allows for patient data to be collected and assembled in a way that tells a story. The specialist from each field can then discuss and weigh the benefits and risks for each diagnostic test that should be performed for the workup in each patient. Physicians who refer their patients to the tumor board use their recommendations to both confirm the diagnosis and shift their treatment plans, depending on the information presented during the meeting.¹ There may be a change in the tumor type, decision to refer for surgery, cancer staging, and list of viable options, especially after reviewing pathology and imaging.² The discussion of the treatment plan may consider not only surgical considerations but also the patient’s quality of life. At times, noninvasive interventions are more appropriate and align with the patient’s goals of care. In addition, during the tumor board clinic there may be new tumors that are identified and biopsied, providing increased diagnosis and surveillance for patients who may have a higher risk for developing skin cancer.

Education for Residents and Providers

The multidisciplinary tumor board not only helps patients but also educates both residents and providers on the evidence-based therapeutic management of high-risk tumors.² Research literature on cutaneous oncology is dynamic, and the weekly tumor board meetings help providers stay informed about the best and most effective treatments for their patients.³ In addition to the attending specialists, participants of the tumor board also may include residents, medical students, medical assistance staff, nurses, physician assistants, and fellows. Furthermore, the recommendations given by the tumor board serve to educate both the patient and the provider who referred them to the tumor board. Although we have access to excellent dermatology textbooks as residents, the most impactful educational experience is seeing the patients in tumor board clinic and participating in the immensely educational discussions at the weekly conferences. Through this experience, I have learned that treatment plans should be personalized to the patient. There are many factors to take into consideration when deciphering what the best course of treatment will be for a patient. Sometimes the best option is Mohs micrographic surgery, while other times it may be scheduling several sessions of palliative radiation oncology. Treatment depends on the individual patient and their condition.

Coordination of Care

During a week that I was on call, I was consulted to biopsy a patient with a giant hemorrhagic basal cell carcinoma that caused substantial cheek and nose distortion as well as anemia secondary to acute blood loss. The patient not only did not have a dermatologist but also did not have a primary care physician given he had not had contact with the health care system in more than 30 years. The reason for him not seeking care was multifactorial, but the approach to his care became multidisciplinary. We sought to connect him with the right providers to help him in any way that we could. We presented him at our multidisciplinary tumor board and started him on sonedigib, a medication that binds to and inhibits the smoothened protein.⁴ Through the tumor board, we were able to establish sustained contact with the patient. The tumor board created effective communication between providers to get him the referrals that he needed for dermatology, pathology, radiation oncology, hematology/oncology, and otolaryngology. The discussions centered around being cognizant of the patient’s apprehension with the health care system as well as providing medical and surgical treatment that would help his quality of life. We built a consensus on what the best plan was for the patient and his family. This consensus would have been more difficult had it not been for the combined specialties of the tumor board. In general, studies have shown that weekly tumor boards have resulted in decreased mortality rates for patients with advanced cancers.⁵

Final Thoughts

The multidisciplinary tumor board is a powerful resource for hospitals and the greater medical community. At these weekly conferences you realize there may still be hope that begins at the line where your expertise ends. It represents a team of providers who compassionately refuse to give up on patients when they are the last refuge.

Multidisciplinary tumor boards are composed of providers from many fields who deliver coordinated care for patients with unresectable and high-risk skin cancers. Providers who comprise the tumor board often are radiation oncologists, hematologists/oncologists, general surgeons, dermatologists, dermatologic surgeons, and pathologists. The benefit of having a tumor board is that each patient is evaluated simultaneously by a group of physicians from various specialties who bring diverse perspectives that will contribute to the overall treatment plan. The cases often encompass high-risk tumors including unresectable basal cell carcinomas or invasive melanomas. By combining knowledge from each specialty in a team approach, the tumor board can effectively and holistically develop a care plan for each patient.

For the tumor board at the Warren Alpert Medical School of Brown University (Providence, Rhode Island), we often prepare a presentation with comprehensive details about the patient and tumor. During the presentation, we also propose a treatment plan prior to describing each patient at the weekly conference and amend the plans during the discussion. Tumor boards also provide a consulting role to the community and hospital providers in which patients are being referred by their primary provider and are seeking a second opinion or guidance.

In many ways, the tumor board is a multidisciplinary approach for patient advocacy in the form of treatment. These physicians meet on a regular basis to check on the patient’s progress and continually reevaluate how to have discussions about the patient’s care. There are many reasons why it is important to refer patients to a multidisciplinary tumor board.

Improved Workup and Diagnosis

One of the values of a tumor board is that it allows for patient data to be collected and assembled in a way that tells a story. The specialist from each field can then discuss and weigh the benefits and risks for each diagnostic test that should be performed for the workup in each patient. Physicians who refer their patients to the tumor board use their recommendations to both confirm the diagnosis and shift their treatment plans, depending on the information presented during the meeting.¹ There may be a change in the tumor type, decision to refer for surgery, cancer staging, and list of viable options, especially after reviewing pathology and imaging.² The discussion of the treatment plan may consider not only surgical considerations but also the patient’s quality of life. At times, noninvasive interventions are more appropriate and align with the patient’s goals of care. In addition, during the tumor board clinic there may be new tumors that are identified and biopsied, providing increased diagnosis and surveillance for patients who may have a higher risk for developing skin cancer.

Education for Residents and Providers

The multidisciplinary tumor board not only helps patients but also educates both residents and providers on the evidence-based therapeutic management of high-risk tumors.² Research literature on cutaneous oncology is dynamic, and the weekly tumor board meetings help providers stay informed about the best and most effective treatments for their patients.³ In addition to the attending specialists, participants of the tumor board also may include residents, medical students, medical assistance staff, nurses, physician assistants, and fellows. Furthermore, the recommendations given by the tumor board serve to educate both the patient and the provider who referred them to the tumor board. Although we have access to excellent dermatology textbooks as residents, the most impactful educational experience is seeing the patients in tumor board clinic and participating in the immensely educational discussions at the weekly conferences. Through this experience, I have learned that treatment plans should be personalized to the patient. There are many factors to take into consideration when deciphering what the best course of treatment will be for a patient. Sometimes the best option is Mohs micrographic surgery, while other times it may be scheduling several sessions of palliative radiation oncology. Treatment depends on the individual patient and their condition.

Coordination of Care

During a week that I was on call, I was consulted to biopsy a patient with a giant hemorrhagic basal cell carcinoma that caused substantial cheek and nose distortion as well as anemia secondary to acute blood loss. The patient not only did not have a dermatologist but also did not have a primary care physician given he had not had contact with the health care system in more than 30 years. The reason for him not seeking care was multifactorial, but the approach to his care became multidisciplinary. We sought to connect him with the right providers to help him in any way that we could. We presented him at our multidisciplinary tumor board and started him on sonedigib, a medication that binds to and inhibits the smoothened protein.⁴ Through the tumor board, we were able to establish sustained contact with the patient. The tumor board created effective communication between providers to get him the referrals that he needed for dermatology, pathology, radiation oncology, hematology/oncology, and otolaryngology. The discussions centered around being cognizant of the patient’s apprehension with the health care system as well as providing medical and surgical treatment that would help his quality of life. We built a consensus on what the best plan was for the patient and his family. This consensus would have been more difficult had it not been for the combined specialties of the tumor board. In general, studies have shown that weekly tumor boards have resulted in decreased mortality rates for patients with advanced cancers.⁵

Final Thoughts

The multidisciplinary tumor board is a powerful resource for hospitals and the greater medical community. At these weekly conferences you realize there may still be hope that begins at the line where your expertise ends. It represents a team of providers who compassionately refuse to give up on patients when they are the last refuge.

Multidisciplinary tumor boards are composed of providers from many fields who deliver coordinated care for patients with unresectable and high-risk skin cancers. Providers who comprise the tumor board often are radiation oncologists, hematologists/oncologists, general surgeons, dermatologists, dermatologic surgeons, and pathologists. The benefit of having a tumor board is that each patient is evaluated simultaneously by a group of physicians from various specialties who bring diverse perspectives that will contribute to the overall treatment plan. The cases often encompass high-risk tumors including unresectable basal cell carcinomas or invasive melanomas. By combining knowledge from each specialty in a team approach, the tumor board can effectively and holistically develop a care plan for each patient.

For the tumor board at the Warren Alpert Medical School of Brown University (Providence, Rhode Island), we often prepare a presentation with comprehensive details about the patient and tumor. During the presentation, we also propose a treatment plan prior to describing each patient at the weekly conference and amend the plans during the discussion. Tumor boards also provide a consulting role to the community and hospital providers in which patients are being referred by their primary provider and are seeking a second opinion or guidance.

In many ways, the tumor board is a multidisciplinary approach for patient advocacy in the form of treatment. These physicians meet on a regular basis to check on the patient’s progress and continually reevaluate how to have discussions about the patient’s care. There are many reasons why it is important to refer patients to a multidisciplinary tumor board.

Improved Workup and Diagnosis

One of the values of a tumor board is that it allows for patient data to be collected and assembled in a way that tells a story. The specialist from each field can then discuss and weigh the benefits and risks for each diagnostic test that should be performed for the workup in each patient. Physicians who refer their patients to the tumor board use their recommendations to both confirm the diagnosis and shift their treatment plans, depending on the information presented during the meeting.¹ There may be a change in the tumor type, decision to refer for surgery, cancer staging, and list of viable options, especially after reviewing pathology and imaging.² The discussion of the treatment plan may consider not only surgical considerations but also the patient’s quality of life. At times, noninvasive interventions are more appropriate and align with the patient’s goals of care. In addition, during the tumor board clinic there may be new tumors that are identified and biopsied, providing increased diagnosis and surveillance for patients who may have a higher risk for developing skin cancer.

Education for Residents and Providers

The multidisciplinary tumor board not only helps patients but also educates both residents and providers on the evidence-based therapeutic management of high-risk tumors.² Research literature on cutaneous oncology is dynamic, and the weekly tumor board meetings help providers stay informed about the best and most effective treatments for their patients.³ In addition to the attending specialists, participants of the tumor board also may include residents, medical students, medical assistance staff, nurses, physician assistants, and fellows. Furthermore, the recommendations given by the tumor board serve to educate both the patient and the provider who referred them to the tumor board. Although we have access to excellent dermatology textbooks as residents, the most impactful educational experience is seeing the patients in tumor board clinic and participating in the immensely educational discussions at the weekly conferences. Through this experience, I have learned that treatment plans should be personalized to the patient. There are many factors to take into consideration when deciphering what the best course of treatment will be for a patient. Sometimes the best option is Mohs micrographic surgery, while other times it may be scheduling several sessions of palliative radiation oncology. Treatment depends on the individual patient and their condition.

Coordination of Care

During a week that I was on call, I was consulted to biopsy a patient with a giant hemorrhagic basal cell carcinoma that caused substantial cheek and nose distortion as well as anemia secondary to acute blood loss. The patient not only did not have a dermatologist but also did not have a primary care physician given he had not had contact with the health care system in more than 30 years. The reason for him not seeking care was multifactorial, but the approach to his care became multidisciplinary. We sought to connect him with the right providers to help him in any way that we could. We presented him at our multidisciplinary tumor board and started him on sonedigib, a medication that binds to and inhibits the smoothened protein.⁴ Through the tumor board, we were able to establish sustained contact with the patient. The tumor board created effective communication between providers to get him the referrals that he needed for dermatology, pathology, radiation oncology, hematology/oncology, and otolaryngology. The discussions centered around being cognizant of the patient’s apprehension with the health care system as well as providing medical and surgical treatment that would help his quality of life. We built a consensus on what the best plan was for the patient and his family. This consensus would have been more difficult had it not been for the combined specialties of the tumor board. In general, studies have shown that weekly tumor boards have resulted in decreased mortality rates for patients with advanced cancers.⁵

Final Thoughts

The multidisciplinary tumor board is a powerful resource for hospitals and the greater medical community. At these weekly conferences you realize there may still be hope that begins at the line where your expertise ends. It represents a team of providers who compassionately refuse to give up on patients when they are the last refuge.