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"Effortless.” “Weightless.” “Limitless.” “Carefree.” In most cases, these are words one would not commonly associate with running. In fact, many people might experience an uptick in anxiety when fathoming the idea of going out for a run. Believe it or not, these words are direct quotes from runners describing the feeling of a “runner’s high”—a well-documented organic euphoria that cannot be purchased or abused. But how is the innately basic and monotonous act of running able to reliably transform something as complex as human emotion? This answer lies in the endocannabinoid system.

For decades, scientists and the public believed the runner’s high was associated with an exercise-induced increase in levels of opioid peptides called beta-endorphins. The problem with this theory is that beta-endorphin, released into the blood by the pituitary gland in response to exercise and stress, has difficulty passing through the blood-brain barrier, rendering central effects of this peripheral opioid unlikely.¹ Only recently have researchers been examining the effects of exercise as it pertains to the endocannabinoid system.² Interest in the study of this system is peaking as use of cannabis and hemp-based products reaches an all-time high.

Exploring the endocannabinoid system

Within the last 25 years, the endocannabinoid system has emerged as a highly relevant and unique neuromodulatory system. As with other neurotransmitter systems, the endocannabinoid system is comprised of the endogenous cannabinoids, their receptors, and an array of enzymes responsible for both synthesis and degradation. Endocannabinoid receptors are ubiquitous in the brain and take effect primarily in the cortex, amygdala, basal ganglia, hippocampus, hypothalamus, and cerebellum. One fascinating feature of endocannabinoids is that their precursors lie embedded within lipid membranes. Nearly on demand, endocannabinoids can be rapidly synthesized and released. This grants them almost immediate availability to get into the action at the synapse.²

One study of mice found that those who were exercised experienced improvements in anxiety behaviors and better tolerance to pain. Further, when the exercised mice were treated with endocannabinoid receptor antagonists, they remained anxious and were more sensitive to pain. Endorphin antagonists had no effect on the outcome of these tests.¹ A similar study conducted in humans found improvement in subjective anxiety scores after 45 minutes of moderate-intensity exercise. This study also showed no change with naltrexone administration vs placebo, again supporting the hypothesis that endorphins play little role in this phenomenon. Interestingly, levels of endogenous cannabinoids were elevated following exercise.³ These findings suggest a possible link between activation of the endogenous endocannabinoid system and the anxiolytic properties of exercise.

For good reason, the endocannabinoid system has attracted substantial interest as a focus for a new class of drugs to treat anxiety and stress-related disorders. It remains unknown how we can best harness its many beneficial effects in a safe and effective manner. With that said, activities such as physical exercise, mindfulness meditation, yoga, and other forms of complementary medicine are immediately available and cost-effective methods that have at least preliminary data revealing their multiple health benefits, including improvement in the symptoms of anxiety and activation of endogenous cannabinoids.^1,3-6

As we are all aware, medical training and practice is full of a variety of stresses and demands. Given these demands, finding a balance between mind, body, and spirit can seem like an impossible task. Besides the obvious physical benefits of regular exercise, running can serve to employ the stress-modifying effects of our endogenous cannabinoid system to reduce perceived anxiety and improve wellness. Indeed, at the start of any bout of exercise—especially running—the transition from rest can be startling. Rest assured that there is good news waiting beyond the first few miles. Your reward for patience and perseverance is a beautiful freedom experienced only by those who have earned it. The best part of it all? It is waiting for you right outside your door.

"Effortless.” “Weightless.” “Limitless.” “Carefree.” In most cases, these are words one would not commonly associate with running. In fact, many people might experience an uptick in anxiety when fathoming the idea of going out for a run. Believe it or not, these words are direct quotes from runners describing the feeling of a “runner’s high”—a well-documented organic euphoria that cannot be purchased or abused. But how is the innately basic and monotonous act of running able to reliably transform something as complex as human emotion? This answer lies in the endocannabinoid system.

For decades, scientists and the public believed the runner’s high was associated with an exercise-induced increase in levels of opioid peptides called beta-endorphins. The problem with this theory is that beta-endorphin, released into the blood by the pituitary gland in response to exercise and stress, has difficulty passing through the blood-brain barrier, rendering central effects of this peripheral opioid unlikely.¹ Only recently have researchers been examining the effects of exercise as it pertains to the endocannabinoid system.² Interest in the study of this system is peaking as use of cannabis and hemp-based products reaches an all-time high.

Exploring the endocannabinoid system

Within the last 25 years, the endocannabinoid system has emerged as a highly relevant and unique neuromodulatory system. As with other neurotransmitter systems, the endocannabinoid system is comprised of the endogenous cannabinoids, their receptors, and an array of enzymes responsible for both synthesis and degradation. Endocannabinoid receptors are ubiquitous in the brain and take effect primarily in the cortex, amygdala, basal ganglia, hippocampus, hypothalamus, and cerebellum. One fascinating feature of endocannabinoids is that their precursors lie embedded within lipid membranes. Nearly on demand, endocannabinoids can be rapidly synthesized and released. This grants them almost immediate availability to get into the action at the synapse.²

One study of mice found that those who were exercised experienced improvements in anxiety behaviors and better tolerance to pain. Further, when the exercised mice were treated with endocannabinoid receptor antagonists, they remained anxious and were more sensitive to pain. Endorphin antagonists had no effect on the outcome of these tests.¹ A similar study conducted in humans found improvement in subjective anxiety scores after 45 minutes of moderate-intensity exercise. This study also showed no change with naltrexone administration vs placebo, again supporting the hypothesis that endorphins play little role in this phenomenon. Interestingly, levels of endogenous cannabinoids were elevated following exercise.³ These findings suggest a possible link between activation of the endogenous endocannabinoid system and the anxiolytic properties of exercise.

For good reason, the endocannabinoid system has attracted substantial interest as a focus for a new class of drugs to treat anxiety and stress-related disorders. It remains unknown how we can best harness its many beneficial effects in a safe and effective manner. With that said, activities such as physical exercise, mindfulness meditation, yoga, and other forms of complementary medicine are immediately available and cost-effective methods that have at least preliminary data revealing their multiple health benefits, including improvement in the symptoms of anxiety and activation of endogenous cannabinoids.^1,3-6

As we are all aware, medical training and practice is full of a variety of stresses and demands. Given these demands, finding a balance between mind, body, and spirit can seem like an impossible task. Besides the obvious physical benefits of regular exercise, running can serve to employ the stress-modifying effects of our endogenous cannabinoid system to reduce perceived anxiety and improve wellness. Indeed, at the start of any bout of exercise—especially running—the transition from rest can be startling. Rest assured that there is good news waiting beyond the first few miles. Your reward for patience and perseverance is a beautiful freedom experienced only by those who have earned it. The best part of it all? It is waiting for you right outside your door.

"Effortless.” “Weightless.” “Limitless.” “Carefree.” In most cases, these are words one would not commonly associate with running. In fact, many people might experience an uptick in anxiety when fathoming the idea of going out for a run. Believe it or not, these words are direct quotes from runners describing the feeling of a “runner’s high”—a well-documented organic euphoria that cannot be purchased or abused. But how is the innately basic and monotonous act of running able to reliably transform something as complex as human emotion? This answer lies in the endocannabinoid system.

For decades, scientists and the public believed the runner’s high was associated with an exercise-induced increase in levels of opioid peptides called beta-endorphins. The problem with this theory is that beta-endorphin, released into the blood by the pituitary gland in response to exercise and stress, has difficulty passing through the blood-brain barrier, rendering central effects of this peripheral opioid unlikely.¹ Only recently have researchers been examining the effects of exercise as it pertains to the endocannabinoid system.² Interest in the study of this system is peaking as use of cannabis and hemp-based products reaches an all-time high.

Exploring the endocannabinoid system

Within the last 25 years, the endocannabinoid system has emerged as a highly relevant and unique neuromodulatory system. As with other neurotransmitter systems, the endocannabinoid system is comprised of the endogenous cannabinoids, their receptors, and an array of enzymes responsible for both synthesis and degradation. Endocannabinoid receptors are ubiquitous in the brain and take effect primarily in the cortex, amygdala, basal ganglia, hippocampus, hypothalamus, and cerebellum. One fascinating feature of endocannabinoids is that their precursors lie embedded within lipid membranes. Nearly on demand, endocannabinoids can be rapidly synthesized and released. This grants them almost immediate availability to get into the action at the synapse.²

One study of mice found that those who were exercised experienced improvements in anxiety behaviors and better tolerance to pain. Further, when the exercised mice were treated with endocannabinoid receptor antagonists, they remained anxious and were more sensitive to pain. Endorphin antagonists had no effect on the outcome of these tests.¹ A similar study conducted in humans found improvement in subjective anxiety scores after 45 minutes of moderate-intensity exercise. This study also showed no change with naltrexone administration vs placebo, again supporting the hypothesis that endorphins play little role in this phenomenon. Interestingly, levels of endogenous cannabinoids were elevated following exercise.³ These findings suggest a possible link between activation of the endogenous endocannabinoid system and the anxiolytic properties of exercise.

For good reason, the endocannabinoid system has attracted substantial interest as a focus for a new class of drugs to treat anxiety and stress-related disorders. It remains unknown how we can best harness its many beneficial effects in a safe and effective manner. With that said, activities such as physical exercise, mindfulness meditation, yoga, and other forms of complementary medicine are immediately available and cost-effective methods that have at least preliminary data revealing their multiple health benefits, including improvement in the symptoms of anxiety and activation of endogenous cannabinoids.^1,3-6

As we are all aware, medical training and practice is full of a variety of stresses and demands. Given these demands, finding a balance between mind, body, and spirit can seem like an impossible task. Besides the obvious physical benefits of regular exercise, running can serve to employ the stress-modifying effects of our endogenous cannabinoid system to reduce perceived anxiety and improve wellness. Indeed, at the start of any bout of exercise—especially running—the transition from rest can be startling. Rest assured that there is good news waiting beyond the first few miles. Your reward for patience and perseverance is a beautiful freedom experienced only by those who have earned it. The best part of it all? It is waiting for you right outside your door.

The COVID-19 pandemic has markedly changed the dermatology residency application process. As medical students head into this application cycle, the impacts of systemic racism and deeply rooted structural barriers continue to be exacerbated for students who identify as an underrepresented minority (URM) in medicine—historically defined as those who self-identify as Hispanic or Latinx; Black or African American; American Indian or Alaska Native; or Native Hawaiian or Pacific Islander. The Association of American Medical Colleges (AAMC) defines URMs as racial and ethnic populations that are underrepresented in medicine relative to their numbers in the general population.¹ Although these groups account for approximately 34% of the population of the United States, they constitute only 11% of the country’s physician workforce.^2,3

Of the total physician workforce in the United States, Black and African American physicians account for 5% of practicing physicians; Hispanic physicians, 5.8%; American Indian and Alaska Native physicians, 0.3%; and Native Hawaiian and Pacific Islander physicians, 0.1%.² In competitive medical specialties, the disproportionality of these numbers compared to our current demographics in the United States as shown above is even more staggering. In 2018, for example, 10% of practicing dermatologists identified as female URM physicians; 6%, as male URM physicians.² In this article, we discuss some of the challenges and considerations for URM students applying to dermatology residency in the era of the COVID-19 pandemic.

Barriers for URM Students in Dermatology

Multiple studies have attempted to identify some of the barriers faced by URM students in medicine that might explain the lack of diversity in competitive specialties. Vasquez and colleagues⁴ identified 4 major factors that play a role in dermatology: lack of equitable resources, lack of support, financial limitations, and the lack of group identity. More than half of URM students surveyed (1) identified lack of support as a barrier and (2) reported having been encouraged to seek a specialty more reflective of their community.⁴

Soliman et al⁵ reported that URM barriers in dermatology extend to include lack of diversity in the field, socioeconomic factors, lack of mentorship, and a negative perception of minority students by residency programs. Dermatology is the second least diverse specialty in medicine after orthopedic surgery, which, in and of itself, might further discourage URM students from applying to dermatology.⁵

With the minimal exposure that URM students have to the field of dermatology, the lack of pipeline programs, and reports that URMs often are encouraged to pursue primary care, the current diversity deficiency in dermatology comes as no surprise. In addition, the substantial disadvantage for URM students is perpetuated by the traditional highly selective process that favors grades, board scores, and honor society status over holistic assessment of the individual student and their unique experiences and potential for contribution.

Looking Beyond Test Scores

The US Medical Licensing Examination (USMLE) traditionally has been used to select dermatology residency applicants, with high cutoff scores often excluding outstanding URM students. Research has suggested that the use of USMLE examination test scores for residency recruitment lacks validity because it has poor predictability of residency performance.⁶ Although the USMLE Step 1 examination is transitioning to pass/fail scoring, applicants for the next cycle will still have a 3-digit numerical score.

We strongly recommend that dermatology programs transition from emphasizing scores of residency candidates to reviewing each candidate holistically. The AAMC defines “holistic review” as a “flexible, individualized way of assessing an applicant’s capabilities, by which balanced consideration is given to experiences, attributes, competencies, and academic or scholarly metrics and, when considered in combination, how the individual might contribute value to the institution’s mission.”⁷ Furthermore, we recommend that dermatology residency programs have multiple faculty members review each application, including a representative of the diversity, inclusion, and equity committee.

In the COVID-19 era, dermatology externship opportunities that would have allowed URM students to work directly with potential residency programs, showcase their abilities, and network have been limited. Virtual residency interviews could make it more challenging to evaluate candidates, especially URM students from less prestigious programs or unusual socioeconomic backgrounds, or with lower board scores. In addition, virtual interviews can more easily become one-dimensional, depriving URM students of the opportunity to gauge their personal fit in a specific dermatology residency program and its community. Questions and concerns of URM students might include: Will I be appropriately supported and mentored? Will my cultural preferences, religion, sexual preference, hairstyle, and beliefs be accepted? Can I advocate for minorities and support antiracism and diversity and inclusion initiatives? To that end, we recommend that dermatology programs continue to host virtual meet-and-greet events for potential students to meet faculty and learn more about the program. In addition, programs should consider having current residents interact virtually with candidates to allow students to better understand the culture of the department and residents’ experiences as trainees in such an environment. For URM students, this is highly important because diversity, inclusion, and antiracism policies and initiatives might not be explicitly available on the institution’s website or residency information page.

Organizations Championing Diversity

Recently, multiple dermatology societies and organizations have been emphasizing the need for diversity and inclusion as well as promoting holistic application review. The American Academy of Dermatology pioneered the Diversity Champion Workshop in 2019 and continues to offer the Diversity Mentorship program, connecting URM students to mentors nationally. The Skin of Color Society offers yearly grants and awards to medical students to develop mentorship and research, and recently hosted webinars to guide medical students and residency programs on diversity and inclusion, residency application and review, and COVID-19 virtual interviews. Other national societies, such as the Student National Medical Association and Latino Medical Student Association, have been promoting workshops and interview mentoring for URM students, including dermatology-specific events. Although it is estimated that more than 90% of medical schools in the United States already perform holistic application review and that such review has been adopted by many dermatology programs nationwide, data regarding dermatology residency programs’ implementation of holistic application review are lacking.⁸

In addition, we encourage continuation of the proposed coordinated interview invite release from the Association of Professors of Dermatology, which was implemented in the 2020-2021 cycle. In light of the recent AAMC letter⁹ on the maldistribution of interview invitations to highest-tier applicants, coordination of interview release dates and other similar initiatives to prevent programs from offering more invites than their available slots and improve transparency about interview days are needed. Furthermore, continuing to offer optional virtual interviews for applicants in future cycles could make the process less cost-prohibitive for many URM students.^4,5

Final Thoughts

Dermatology residency programs must intentionally guard against falling back to traditional standards of assessment as the only means of student evaluation, especially in this virtual era. It is our responsibility to remove artificial barriers that continue to stall progress in diversity, inclusion, equity, and belonging in dermatology.

The COVID-19 pandemic has markedly changed the dermatology residency application process. As medical students head into this application cycle, the impacts of systemic racism and deeply rooted structural barriers continue to be exacerbated for students who identify as an underrepresented minority (URM) in medicine—historically defined as those who self-identify as Hispanic or Latinx; Black or African American; American Indian or Alaska Native; or Native Hawaiian or Pacific Islander. The Association of American Medical Colleges (AAMC) defines URMs as racial and ethnic populations that are underrepresented in medicine relative to their numbers in the general population.¹ Although these groups account for approximately 34% of the population of the United States, they constitute only 11% of the country’s physician workforce.^2,3

Of the total physician workforce in the United States, Black and African American physicians account for 5% of practicing physicians; Hispanic physicians, 5.8%; American Indian and Alaska Native physicians, 0.3%; and Native Hawaiian and Pacific Islander physicians, 0.1%.² In competitive medical specialties, the disproportionality of these numbers compared to our current demographics in the United States as shown above is even more staggering. In 2018, for example, 10% of practicing dermatologists identified as female URM physicians; 6%, as male URM physicians.² In this article, we discuss some of the challenges and considerations for URM students applying to dermatology residency in the era of the COVID-19 pandemic.

Barriers for URM Students in Dermatology

Multiple studies have attempted to identify some of the barriers faced by URM students in medicine that might explain the lack of diversity in competitive specialties. Vasquez and colleagues⁴ identified 4 major factors that play a role in dermatology: lack of equitable resources, lack of support, financial limitations, and the lack of group identity. More than half of URM students surveyed (1) identified lack of support as a barrier and (2) reported having been encouraged to seek a specialty more reflective of their community.⁴

Soliman et al⁵ reported that URM barriers in dermatology extend to include lack of diversity in the field, socioeconomic factors, lack of mentorship, and a negative perception of minority students by residency programs. Dermatology is the second least diverse specialty in medicine after orthopedic surgery, which, in and of itself, might further discourage URM students from applying to dermatology.⁵

With the minimal exposure that URM students have to the field of dermatology, the lack of pipeline programs, and reports that URMs often are encouraged to pursue primary care, the current diversity deficiency in dermatology comes as no surprise. In addition, the substantial disadvantage for URM students is perpetuated by the traditional highly selective process that favors grades, board scores, and honor society status over holistic assessment of the individual student and their unique experiences and potential for contribution.

Looking Beyond Test Scores

The US Medical Licensing Examination (USMLE) traditionally has been used to select dermatology residency applicants, with high cutoff scores often excluding outstanding URM students. Research has suggested that the use of USMLE examination test scores for residency recruitment lacks validity because it has poor predictability of residency performance.⁶ Although the USMLE Step 1 examination is transitioning to pass/fail scoring, applicants for the next cycle will still have a 3-digit numerical score.

We strongly recommend that dermatology programs transition from emphasizing scores of residency candidates to reviewing each candidate holistically. The AAMC defines “holistic review” as a “flexible, individualized way of assessing an applicant’s capabilities, by which balanced consideration is given to experiences, attributes, competencies, and academic or scholarly metrics and, when considered in combination, how the individual might contribute value to the institution’s mission.”⁷ Furthermore, we recommend that dermatology residency programs have multiple faculty members review each application, including a representative of the diversity, inclusion, and equity committee.

In the COVID-19 era, dermatology externship opportunities that would have allowed URM students to work directly with potential residency programs, showcase their abilities, and network have been limited. Virtual residency interviews could make it more challenging to evaluate candidates, especially URM students from less prestigious programs or unusual socioeconomic backgrounds, or with lower board scores. In addition, virtual interviews can more easily become one-dimensional, depriving URM students of the opportunity to gauge their personal fit in a specific dermatology residency program and its community. Questions and concerns of URM students might include: Will I be appropriately supported and mentored? Will my cultural preferences, religion, sexual preference, hairstyle, and beliefs be accepted? Can I advocate for minorities and support antiracism and diversity and inclusion initiatives? To that end, we recommend that dermatology programs continue to host virtual meet-and-greet events for potential students to meet faculty and learn more about the program. In addition, programs should consider having current residents interact virtually with candidates to allow students to better understand the culture of the department and residents’ experiences as trainees in such an environment. For URM students, this is highly important because diversity, inclusion, and antiracism policies and initiatives might not be explicitly available on the institution’s website or residency information page.

Organizations Championing Diversity

Recently, multiple dermatology societies and organizations have been emphasizing the need for diversity and inclusion as well as promoting holistic application review. The American Academy of Dermatology pioneered the Diversity Champion Workshop in 2019 and continues to offer the Diversity Mentorship program, connecting URM students to mentors nationally. The Skin of Color Society offers yearly grants and awards to medical students to develop mentorship and research, and recently hosted webinars to guide medical students and residency programs on diversity and inclusion, residency application and review, and COVID-19 virtual interviews. Other national societies, such as the Student National Medical Association and Latino Medical Student Association, have been promoting workshops and interview mentoring for URM students, including dermatology-specific events. Although it is estimated that more than 90% of medical schools in the United States already perform holistic application review and that such review has been adopted by many dermatology programs nationwide, data regarding dermatology residency programs’ implementation of holistic application review are lacking.⁸

In addition, we encourage continuation of the proposed coordinated interview invite release from the Association of Professors of Dermatology, which was implemented in the 2020-2021 cycle. In light of the recent AAMC letter⁹ on the maldistribution of interview invitations to highest-tier applicants, coordination of interview release dates and other similar initiatives to prevent programs from offering more invites than their available slots and improve transparency about interview days are needed. Furthermore, continuing to offer optional virtual interviews for applicants in future cycles could make the process less cost-prohibitive for many URM students.^4,5

Final Thoughts

Dermatology residency programs must intentionally guard against falling back to traditional standards of assessment as the only means of student evaluation, especially in this virtual era. It is our responsibility to remove artificial barriers that continue to stall progress in diversity, inclusion, equity, and belonging in dermatology.

The COVID-19 pandemic has markedly changed the dermatology residency application process. As medical students head into this application cycle, the impacts of systemic racism and deeply rooted structural barriers continue to be exacerbated for students who identify as an underrepresented minority (URM) in medicine—historically defined as those who self-identify as Hispanic or Latinx; Black or African American; American Indian or Alaska Native; or Native Hawaiian or Pacific Islander. The Association of American Medical Colleges (AAMC) defines URMs as racial and ethnic populations that are underrepresented in medicine relative to their numbers in the general population.¹ Although these groups account for approximately 34% of the population of the United States, they constitute only 11% of the country’s physician workforce.^2,3

Of the total physician workforce in the United States, Black and African American physicians account for 5% of practicing physicians; Hispanic physicians, 5.8%; American Indian and Alaska Native physicians, 0.3%; and Native Hawaiian and Pacific Islander physicians, 0.1%.² In competitive medical specialties, the disproportionality of these numbers compared to our current demographics in the United States as shown above is even more staggering. In 2018, for example, 10% of practicing dermatologists identified as female URM physicians; 6%, as male URM physicians.² In this article, we discuss some of the challenges and considerations for URM students applying to dermatology residency in the era of the COVID-19 pandemic.

Barriers for URM Students in Dermatology

Multiple studies have attempted to identify some of the barriers faced by URM students in medicine that might explain the lack of diversity in competitive specialties. Vasquez and colleagues⁴ identified 4 major factors that play a role in dermatology: lack of equitable resources, lack of support, financial limitations, and the lack of group identity. More than half of URM students surveyed (1) identified lack of support as a barrier and (2) reported having been encouraged to seek a specialty more reflective of their community.⁴

Soliman et al⁵ reported that URM barriers in dermatology extend to include lack of diversity in the field, socioeconomic factors, lack of mentorship, and a negative perception of minority students by residency programs. Dermatology is the second least diverse specialty in medicine after orthopedic surgery, which, in and of itself, might further discourage URM students from applying to dermatology.⁵

With the minimal exposure that URM students have to the field of dermatology, the lack of pipeline programs, and reports that URMs often are encouraged to pursue primary care, the current diversity deficiency in dermatology comes as no surprise. In addition, the substantial disadvantage for URM students is perpetuated by the traditional highly selective process that favors grades, board scores, and honor society status over holistic assessment of the individual student and their unique experiences and potential for contribution.

Looking Beyond Test Scores

The US Medical Licensing Examination (USMLE) traditionally has been used to select dermatology residency applicants, with high cutoff scores often excluding outstanding URM students. Research has suggested that the use of USMLE examination test scores for residency recruitment lacks validity because it has poor predictability of residency performance.⁶ Although the USMLE Step 1 examination is transitioning to pass/fail scoring, applicants for the next cycle will still have a 3-digit numerical score.

We strongly recommend that dermatology programs transition from emphasizing scores of residency candidates to reviewing each candidate holistically. The AAMC defines “holistic review” as a “flexible, individualized way of assessing an applicant’s capabilities, by which balanced consideration is given to experiences, attributes, competencies, and academic or scholarly metrics and, when considered in combination, how the individual might contribute value to the institution’s mission.”⁷ Furthermore, we recommend that dermatology residency programs have multiple faculty members review each application, including a representative of the diversity, inclusion, and equity committee.

In the COVID-19 era, dermatology externship opportunities that would have allowed URM students to work directly with potential residency programs, showcase their abilities, and network have been limited. Virtual residency interviews could make it more challenging to evaluate candidates, especially URM students from less prestigious programs or unusual socioeconomic backgrounds, or with lower board scores. In addition, virtual interviews can more easily become one-dimensional, depriving URM students of the opportunity to gauge their personal fit in a specific dermatology residency program and its community. Questions and concerns of URM students might include: Will I be appropriately supported and mentored? Will my cultural preferences, religion, sexual preference, hairstyle, and beliefs be accepted? Can I advocate for minorities and support antiracism and diversity and inclusion initiatives? To that end, we recommend that dermatology programs continue to host virtual meet-and-greet events for potential students to meet faculty and learn more about the program. In addition, programs should consider having current residents interact virtually with candidates to allow students to better understand the culture of the department and residents’ experiences as trainees in such an environment. For URM students, this is highly important because diversity, inclusion, and antiracism policies and initiatives might not be explicitly available on the institution’s website or residency information page.

Organizations Championing Diversity

Recently, multiple dermatology societies and organizations have been emphasizing the need for diversity and inclusion as well as promoting holistic application review. The American Academy of Dermatology pioneered the Diversity Champion Workshop in 2019 and continues to offer the Diversity Mentorship program, connecting URM students to mentors nationally. The Skin of Color Society offers yearly grants and awards to medical students to develop mentorship and research, and recently hosted webinars to guide medical students and residency programs on diversity and inclusion, residency application and review, and COVID-19 virtual interviews. Other national societies, such as the Student National Medical Association and Latino Medical Student Association, have been promoting workshops and interview mentoring for URM students, including dermatology-specific events. Although it is estimated that more than 90% of medical schools in the United States already perform holistic application review and that such review has been adopted by many dermatology programs nationwide, data regarding dermatology residency programs’ implementation of holistic application review are lacking.⁸

In addition, we encourage continuation of the proposed coordinated interview invite release from the Association of Professors of Dermatology, which was implemented in the 2020-2021 cycle. In light of the recent AAMC letter⁹ on the maldistribution of interview invitations to highest-tier applicants, coordination of interview release dates and other similar initiatives to prevent programs from offering more invites than their available slots and improve transparency about interview days are needed. Furthermore, continuing to offer optional virtual interviews for applicants in future cycles could make the process less cost-prohibitive for many URM students.^4,5

Final Thoughts

Dermatology residency programs must intentionally guard against falling back to traditional standards of assessment as the only means of student evaluation, especially in this virtual era. It is our responsibility to remove artificial barriers that continue to stall progress in diversity, inclusion, equity, and belonging in dermatology.

A ccording to the US Census Bureau, more than half of all Americans are projected to belong to a minority group, defined as any group other than non-Hispanic White alone, by 2044. ¹ Consequently, the United States rapidly is becoming a country in which the majority of citizens will have skin of color. Individuals with skin of color are of diverse ethnic backgrounds and include people of African, Latin American, Native American, Pacific Islander, and Asian descent, as well as interethnic backgrounds. ² Throughout the country, dermatologists along with primary care practitioners may be confronted with certain cutaneous conditions that have varying disease presentations or processes in patients with skin of color. It also is important to note that racial categories are socially rather than biologically constructed, and the term skin of color includes a wide variety of diverse skin types. Nevertheless, the current literature thoroughly supports unique pathophysiologic differences in skin of color as well as variations in disease manifestation compared to White patients. ^3-5 For example, the increased lability of melanosomes in skin of color patients, which increases their risk for postinflammatory hyperpigmentation, has been well documented. ^5-7 There are various dermatologic conditions that also occur with higher frequency and manifest uniquely in people with darker, more pigmented skin, ^7-9 and dermatologists, along with primary care physicians, should feel prepared to recognize and address them.

Extensive evidence also indicates that there are unique aspects to consider while managing certain skin diseases in patients with skin of color.^8,10,11 Consequently, as noted on the Skin of Color Society (SOCS) website, “[a]n increase in the body of dermatological literature concerning skin of color as well as the advancement of both basic science and clinical investigational research is necessary to meet the needs of the expanding skin of color population.”² In the meantime, current knowledge regarding cutaneous conditions that diversely or disproportionately affect skin of color should be actively disseminated to physicians in training. Although patients with skin of color should always have access to comprehensive care and knowledgeable practitioners, the current changes in national and regional demographics further underscore the need for a more thorough understanding of skin of color with regard to disease pathogenesis, diagnosis, and treatment.

Several studies have found that medical students in the United States are minimally exposed to dermatology in general compared to other clinical specialties,^12-14 which can easily lead to the underrecognition of disorders that may uniquely or disproportionately affect individuals with pigmented skin. Recent data showed that medical schools typically required fewer than 10 hours of dermatology instruction,¹² and on average, dermatologic training made up less than 1% of a medical student’s undergraduate medical education.^13,15,16 Consequently, less than 40% of primary care residents felt that their medical school curriculum adequately prepared them to manage common skin conditions.¹⁴ Although not all physicians should be expected to fully grasp the complexities of skin of color and its diagnostic and therapeutic implications, both practicing and training dermatologists have acknowledged a lack of exposure to skin of color. In one study, approximately 47% of dermatologists and dermatology residents reported that their medical training (medical school and/or residency) was inadequate in training them on skin conditions in Black patients. Furthermore, many who felt their training was lacking in skin of color identified the need for greater exposure to Black patients and training materials.¹⁵ The absence of comprehensive medical education regarding skin of color ultimately can be a disadvantage for both practitioners and patients, resulting in poorer outcomes. Furthermore, underrepresentation of skin of color may persist beyond undergraduate and graduate medical education. There also is evidence to suggest that noninclusion of skin of color pervades foundational dermatologic educational resources, including commonly used textbooks as well as continuing medical education disseminated at national conferences and meetings.¹⁷ Taken together, these findings highlight the need for more diverse and representative exposure to skin of color throughout medical training, which begins with a diverse inclusive undergraduate medical education in dermatology.

The objective of this study was to determine if the preclinical dermatology curriculum at 3 US medical schools provided adequate representation of skin of color patients in their didactic presentation slides.

Methods

Participants—Three US medical schools, a blend of private and public medical schools located across different geographic boundaries, agreed to participate in the study. All 3 institutions were current members of the American Medical Association (AMA) Accelerating Change in Medical Education consortium, whose primary goal is to create the medical school of the future and transform physician training.¹⁸ All 32 member institutions of the AMA consortium were contacted to request their participation in the study. As part of the consortium, these institutions have vowed to collectively work to develop and share the best models for educational advancement to improve care for patients, populations, and communities¹⁸ and would expectedly provide a more racially and ethnically inclusive curriculum than an institution not accountable to a group dedicated to identifying the best ways to deliver care for increasingly diverse communities.

Data Collection—Lectures were included if they were presented during dermatology preclinical courses in the 2015 to 2016 academic year. An uninvolved third party removed the names and identities of instructors to preserve anonymity. Two independent coders from different institutions extracted the data—lecture title, total number of clinical and histologic images, and number of skin of color images—from each of the anonymized lectures using a standardized coding form. We documented differences in skin of color noted in lectures and the disease context for the discussed differences, such as variations in clinical presentation, disease process, epidemiology/risk, and treatment between different skin phenotypes or ethnic groups. Photographs in which the coders were unable to differentiate whether the patient had skin of color were designated as indeterminate or unclear. Photographs appearing to represent Fitzpatrick skin types IV, V, and VI¹⁹ were categorically designated as skin of color, and those appearing to represent Fitzpatrick skin types I and II were described as not skin of color; however, images appearing to represent Fitzpatrick skin type III often were classified as not skin of color or indeterminate and occasionally skin of color. The Figure shows examples of images classified as skin of color, indeterminate, and not skin of color. Photographs often were classified as indeterminate due to poor lighting, close-up view photographs, or highlighted pathology obscuring the surrounding skin. We excluded duplicate photographs and histologic images from the analyses.

We also reviewed 19 conditions previously highlighted by the SOCS as areas of importance to skin of color patients.²⁰ The coders tracked how many of these conditions were noted in each lecture. Duplicate discussion of these conditions was not included in the analyses. Any discrepancies between coders were resolved through additional slide review and discussion. The final coded data with the agreed upon changes were used for statistical analyses. Recent national demographic data from the US Census Bureau in 2019 describe approximately 39.9% of the population as belonging to racial/ethnic groups other than non-Hispanic/Latinx White.²¹ Consequently, the standard for adequate representation for skin of color photographs was set at 35% for the purpose of this study.

Across all 3 institutions included in the study, the proportion of the total number of clinical photographs showing skin of color was 16% (290/1812). Eight percent of the total photographs (145/1812) were noted to be indeterminate (Table). For institution 1, 23.6% of photographs (155/658) showed skin of color, and 12.6% (83/658) were indeterminate. For institution 2, 13.1% (76/578) showed skin of color and 7.8% (45/578) were indeterminate. For institution 3, 10.2% (59/576) showed skin of color and 3% (17/576) were indeterminate.

Institutions 1, 2, and 3 had 18, 8, and 17 total dermatology lectures, respectively. Of the 19 conditions designated as areas of importance to skin of color patients by the SOCS, 16 (84.2%) were discussed by institution 1, 11 (57.9%) by institution 2, and 9 (47.4%) by institution 3 (eTable 1). Institution 3 did not include photographs of skin of color patients in its acne, psoriasis, or cutaneous malignancy lectures. Institution 1 also did not include any skin of color patients in its malignancy lecture. Lectures that focused on pigmentary disorders, atopic dermatitis, infectious conditions, and benign cutaneous neoplasms were more likely to display photographs of skin of color patients; for example, lectures that discussed infectious conditions, such as superficial mycoses, herpes viruses, human papillomavirus, syphilis, and atypical mycobacterial infections, were consistently among those with higher proportions of photographs of skin of color patients.

Throughout the entire preclinical dermatology course at all 3 institutions, of 2945 lecture slides, only 24 (0.8%) unique differences were noted between skin color and non–skin of color patients, with 10 total differences noted by institution 1, 6 by institution 2, and 8 by institution 3 (Table). The majority of these differences (19/24) were related to epidemiologic differences in prevalence among varying racial/ethnic groups, with only 5 instances highlighting differences in clinical presentation. There was only a single instance that elaborated on the underlying pathophysiologic mechanisms of the discussed difference. Of all 24 unique differences discussed, 8 were related to skin cancer, 3 were related to dermatitis, and 2 were related to the difference in manifestation of erythema in patients with darker skin (eTable 2).

Comment

The results of this study demonstrated that skin of color is underrepresented in the preclinical dermatology curriculum at these 3 institutions. Although only 16% of all included clinical photographs were of skin of color, individuals with skin of color will soon represent more than half of the total US population within the next 2 decades.¹ To increase representation of skin of color patients, teaching faculty should consciously and deliberately include more photographs of skin of color patients for a wider variety of common conditions, including atopic dermatitis and psoriasis, in addition to those that tend to disparately affect skin of color patients, such as pseudofolliculitis barbae or melasma. Furthermore, they also can incorporate more detailed discussions about important differences seen in skin of color patients.

More Skin of Color Photographs in Psoriasis Lectures—At institution 3, there were no skin of color patients included in the psoriasis lecture, even though there is considerable data in the literature indicating notable differences in the clinical presentation, quality-of-life impact, and treatment of psoriasis in skin of color patients.^11,22 There are multiple nuances in psoriasis manifestation in patients with skin of color, including less-conspicuous erythema in darker skin, higher degrees of dyspigmentation, and greater body surface area involvement. For Black patients with scalp psoriasis, the impact of hair texture, styling practices, and washing frequency are additional considerations that may impact disease severity and selection of topical therapy.¹¹ The lack of inclusion of any skin of color patients in the psoriasis lecture at one institution further underscores the pressing need to prioritize communities of color in medical education.

More Skin of Color Photographs in Cutaneous Malignancy Lectures—Similarly, while a lecturer at institution 2 noted that acral lentiginous melanoma accounts for a considerable proportion of melanoma among skin of color patients,²³ there was no mention of how melanoma generally is substantially more deadly in this population, potentially due to decreased awareness and inconsistent screening.²⁴ Furthermore, at institutions 1 and 3, there were no photographs or discussion of skin of color patients during the cutaneous malignancy lectures. Evidence shows that more emphasis is needed for melanoma screening and awareness in skin of color populations to improve survival outcomes,²⁴ and this begins with educating not only future dermatologists but all future physicians as well. The failure to include photographs of skin of color patients in discussions or lectures regarding cutaneous malignancies may serve to further perpetuate the harmful misperception that individuals with skin of color are unaffected by skin cancer.^25,26

Analysis of Skin of Color Photographs in Infectious Disease Lectures—In addition, lectures discussing infectious etiologies were among those with the highest proportion of skin of color photographs. This relatively disproportionate representation of skin of color compared to the other lectures may contribute to the development of harmful stereotypes or the stigmatization of skin of color patients. Although skin of color should continue to be represented in similar lectures, teaching faculty should remain mindful of the potential unintended impact from lectures including relatively disproportionate amounts of skin of color, particularly when other lectures may have sparse to absent representation of skin of color.

More Photographs Available for Education—Overall, our findings may help to inform changes to preclinical dermatology medical education at other institutions to create more inclusive and representative curricula for skin of color patients. The ability of instructors to provide visual representation of various dermatologic conditions may be limited by the photographs available in certain textbooks with few examples of patients with skin of color; however, concerns regarding the lack of skin of color representation in dermatology training is not a novel discussion.¹⁷ Although it is the responsibility of all dermatologists to advocate for the inclusion of skin of color, many dermatologists of color have been leading the way in this movement for decades, publishing several textbooks to document various skin conditions in those with darker skin types and discuss unique considerations for patients with skin of color.^27-29 Images from these textbooks can be utilized by programs to increase representation of skin of color in dermatology training. There also are multiple expanding online dermatologic databases, such as VisualDx, with an increasing focus on skin of color patients, some of which allow users to filter images by degree of skin pigmentation.³⁰ Moreover, instructors also can work to diversify their curricula by highlighting more of the SOCS conditions of importance to skin of color patients, which have since been renamed and highlighted on the Patient Dermatology Education section of the SOCS website.²⁰ These conditions, while not completely comprehensive, provide a useful starting point for medical educators to reevaluate for potential areas of improvement and inclusion.

There are several potential strategies that can be used to better represent skin of color in dermatologic preclinical medical education, including increasing awareness, especially among dermatology teaching faculty, of existing disparities in the representation of skin of color in the preclinical curricula. Additionally, all dermatology teaching materials could be reviewed at the department level prior to being disseminated to medical students to assess for instances in which skin of color could be prioritized for discussion or varying disease presentations in skin of color could be demonstrated. Finally, teaching faculty may consider photographing more clinical images of their skin of color patients to further develop a catalog of diverse images that can be used to teach students.

Study Limitations—Our study was unable to account for verbal discussion of skin of color not otherwise denoted or captured in lecture slides. Additional limitations include the utilization of Fitzpatrick skin types to describe and differentiate varying skin tones, as the Fitzpatrick scale originally was developed as a method to describe an individual’s response to UV exposure.¹⁹ The inability to further delineate the representation of darker skin types, such as those that may be classified as Fitzpatrick skin types V or VI,¹⁹ compared to those with lighter skin of color also was a limiting factor. This study was unable to assess for discussion of other common conditions affecting skin of color patients that were not listed as one of the priority conditions by SOCS. Photographs that were designated as indeterminate were difficult to elucidate as skin of color; however, it is possible that instructors may have verbally described these images as skin of color during lectures. Nonetheless, it may be beneficial for learners if teaching faculty were to clearly label instances where skin of color patients are shown or when notable differences are present.

Future studies would benefit from the inclusion of audio data from lectures, syllabi, and small group teaching materials from preclinical courses to more accurately assess representation of skin of color in dermatology training. Additionally, future studies also may expand to include images from lectures of overlapping clinical specialties, particularly infectious disease and rheumatology, to provide a broader assessment of skin of color exposure. Furthermore, repeat assessment may be beneficial to assess the longitudinal effectiveness of curricular changes at the institutions included in this study, comparing older lectures to more recent, updated lectures. This study also may be replicated at other medical schools to allow for wider comparison of curricula.

Acknowledgment—The authors wish to thank the institutions that offered and agreed to participate in this study with the hopes of improving medical education.

A ccording to the US Census Bureau, more than half of all Americans are projected to belong to a minority group, defined as any group other than non-Hispanic White alone, by 2044. ¹ Consequently, the United States rapidly is becoming a country in which the majority of citizens will have skin of color. Individuals with skin of color are of diverse ethnic backgrounds and include people of African, Latin American, Native American, Pacific Islander, and Asian descent, as well as interethnic backgrounds. ² Throughout the country, dermatologists along with primary care practitioners may be confronted with certain cutaneous conditions that have varying disease presentations or processes in patients with skin of color. It also is important to note that racial categories are socially rather than biologically constructed, and the term skin of color includes a wide variety of diverse skin types. Nevertheless, the current literature thoroughly supports unique pathophysiologic differences in skin of color as well as variations in disease manifestation compared to White patients. ^3-5 For example, the increased lability of melanosomes in skin of color patients, which increases their risk for postinflammatory hyperpigmentation, has been well documented. ^5-7 There are various dermatologic conditions that also occur with higher frequency and manifest uniquely in people with darker, more pigmented skin, ^7-9 and dermatologists, along with primary care physicians, should feel prepared to recognize and address them.

Extensive evidence also indicates that there are unique aspects to consider while managing certain skin diseases in patients with skin of color.^8,10,11 Consequently, as noted on the Skin of Color Society (SOCS) website, “[a]n increase in the body of dermatological literature concerning skin of color as well as the advancement of both basic science and clinical investigational research is necessary to meet the needs of the expanding skin of color population.”² In the meantime, current knowledge regarding cutaneous conditions that diversely or disproportionately affect skin of color should be actively disseminated to physicians in training. Although patients with skin of color should always have access to comprehensive care and knowledgeable practitioners, the current changes in national and regional demographics further underscore the need for a more thorough understanding of skin of color with regard to disease pathogenesis, diagnosis, and treatment.

Several studies have found that medical students in the United States are minimally exposed to dermatology in general compared to other clinical specialties,^12-14 which can easily lead to the underrecognition of disorders that may uniquely or disproportionately affect individuals with pigmented skin. Recent data showed that medical schools typically required fewer than 10 hours of dermatology instruction,¹² and on average, dermatologic training made up less than 1% of a medical student’s undergraduate medical education.^13,15,16 Consequently, less than 40% of primary care residents felt that their medical school curriculum adequately prepared them to manage common skin conditions.¹⁴ Although not all physicians should be expected to fully grasp the complexities of skin of color and its diagnostic and therapeutic implications, both practicing and training dermatologists have acknowledged a lack of exposure to skin of color. In one study, approximately 47% of dermatologists and dermatology residents reported that their medical training (medical school and/or residency) was inadequate in training them on skin conditions in Black patients. Furthermore, many who felt their training was lacking in skin of color identified the need for greater exposure to Black patients and training materials.¹⁵ The absence of comprehensive medical education regarding skin of color ultimately can be a disadvantage for both practitioners and patients, resulting in poorer outcomes. Furthermore, underrepresentation of skin of color may persist beyond undergraduate and graduate medical education. There also is evidence to suggest that noninclusion of skin of color pervades foundational dermatologic educational resources, including commonly used textbooks as well as continuing medical education disseminated at national conferences and meetings.¹⁷ Taken together, these findings highlight the need for more diverse and representative exposure to skin of color throughout medical training, which begins with a diverse inclusive undergraduate medical education in dermatology.

The objective of this study was to determine if the preclinical dermatology curriculum at 3 US medical schools provided adequate representation of skin of color patients in their didactic presentation slides.

Methods

Participants—Three US medical schools, a blend of private and public medical schools located across different geographic boundaries, agreed to participate in the study. All 3 institutions were current members of the American Medical Association (AMA) Accelerating Change in Medical Education consortium, whose primary goal is to create the medical school of the future and transform physician training.¹⁸ All 32 member institutions of the AMA consortium were contacted to request their participation in the study. As part of the consortium, these institutions have vowed to collectively work to develop and share the best models for educational advancement to improve care for patients, populations, and communities¹⁸ and would expectedly provide a more racially and ethnically inclusive curriculum than an institution not accountable to a group dedicated to identifying the best ways to deliver care for increasingly diverse communities.

Data Collection—Lectures were included if they were presented during dermatology preclinical courses in the 2015 to 2016 academic year. An uninvolved third party removed the names and identities of instructors to preserve anonymity. Two independent coders from different institutions extracted the data—lecture title, total number of clinical and histologic images, and number of skin of color images—from each of the anonymized lectures using a standardized coding form. We documented differences in skin of color noted in lectures and the disease context for the discussed differences, such as variations in clinical presentation, disease process, epidemiology/risk, and treatment between different skin phenotypes or ethnic groups. Photographs in which the coders were unable to differentiate whether the patient had skin of color were designated as indeterminate or unclear. Photographs appearing to represent Fitzpatrick skin types IV, V, and VI¹⁹ were categorically designated as skin of color, and those appearing to represent Fitzpatrick skin types I and II were described as not skin of color; however, images appearing to represent Fitzpatrick skin type III often were classified as not skin of color or indeterminate and occasionally skin of color. The Figure shows examples of images classified as skin of color, indeterminate, and not skin of color. Photographs often were classified as indeterminate due to poor lighting, close-up view photographs, or highlighted pathology obscuring the surrounding skin. We excluded duplicate photographs and histologic images from the analyses.

We also reviewed 19 conditions previously highlighted by the SOCS as areas of importance to skin of color patients.²⁰ The coders tracked how many of these conditions were noted in each lecture. Duplicate discussion of these conditions was not included in the analyses. Any discrepancies between coders were resolved through additional slide review and discussion. The final coded data with the agreed upon changes were used for statistical analyses. Recent national demographic data from the US Census Bureau in 2019 describe approximately 39.9% of the population as belonging to racial/ethnic groups other than non-Hispanic/Latinx White.²¹ Consequently, the standard for adequate representation for skin of color photographs was set at 35% for the purpose of this study.

Across all 3 institutions included in the study, the proportion of the total number of clinical photographs showing skin of color was 16% (290/1812). Eight percent of the total photographs (145/1812) were noted to be indeterminate (Table). For institution 1, 23.6% of photographs (155/658) showed skin of color, and 12.6% (83/658) were indeterminate. For institution 2, 13.1% (76/578) showed skin of color and 7.8% (45/578) were indeterminate. For institution 3, 10.2% (59/576) showed skin of color and 3% (17/576) were indeterminate.

Institutions 1, 2, and 3 had 18, 8, and 17 total dermatology lectures, respectively. Of the 19 conditions designated as areas of importance to skin of color patients by the SOCS, 16 (84.2%) were discussed by institution 1, 11 (57.9%) by institution 2, and 9 (47.4%) by institution 3 (eTable 1). Institution 3 did not include photographs of skin of color patients in its acne, psoriasis, or cutaneous malignancy lectures. Institution 1 also did not include any skin of color patients in its malignancy lecture. Lectures that focused on pigmentary disorders, atopic dermatitis, infectious conditions, and benign cutaneous neoplasms were more likely to display photographs of skin of color patients; for example, lectures that discussed infectious conditions, such as superficial mycoses, herpes viruses, human papillomavirus, syphilis, and atypical mycobacterial infections, were consistently among those with higher proportions of photographs of skin of color patients.

Throughout the entire preclinical dermatology course at all 3 institutions, of 2945 lecture slides, only 24 (0.8%) unique differences were noted between skin color and non–skin of color patients, with 10 total differences noted by institution 1, 6 by institution 2, and 8 by institution 3 (Table). The majority of these differences (19/24) were related to epidemiologic differences in prevalence among varying racial/ethnic groups, with only 5 instances highlighting differences in clinical presentation. There was only a single instance that elaborated on the underlying pathophysiologic mechanisms of the discussed difference. Of all 24 unique differences discussed, 8 were related to skin cancer, 3 were related to dermatitis, and 2 were related to the difference in manifestation of erythema in patients with darker skin (eTable 2).

Comment

The results of this study demonstrated that skin of color is underrepresented in the preclinical dermatology curriculum at these 3 institutions. Although only 16% of all included clinical photographs were of skin of color, individuals with skin of color will soon represent more than half of the total US population within the next 2 decades.¹ To increase representation of skin of color patients, teaching faculty should consciously and deliberately include more photographs of skin of color patients for a wider variety of common conditions, including atopic dermatitis and psoriasis, in addition to those that tend to disparately affect skin of color patients, such as pseudofolliculitis barbae or melasma. Furthermore, they also can incorporate more detailed discussions about important differences seen in skin of color patients.

More Skin of Color Photographs in Psoriasis Lectures—At institution 3, there were no skin of color patients included in the psoriasis lecture, even though there is considerable data in the literature indicating notable differences in the clinical presentation, quality-of-life impact, and treatment of psoriasis in skin of color patients.^11,22 There are multiple nuances in psoriasis manifestation in patients with skin of color, including less-conspicuous erythema in darker skin, higher degrees of dyspigmentation, and greater body surface area involvement. For Black patients with scalp psoriasis, the impact of hair texture, styling practices, and washing frequency are additional considerations that may impact disease severity and selection of topical therapy.¹¹ The lack of inclusion of any skin of color patients in the psoriasis lecture at one institution further underscores the pressing need to prioritize communities of color in medical education.

More Skin of Color Photographs in Cutaneous Malignancy Lectures—Similarly, while a lecturer at institution 2 noted that acral lentiginous melanoma accounts for a considerable proportion of melanoma among skin of color patients,²³ there was no mention of how melanoma generally is substantially more deadly in this population, potentially due to decreased awareness and inconsistent screening.²⁴ Furthermore, at institutions 1 and 3, there were no photographs or discussion of skin of color patients during the cutaneous malignancy lectures. Evidence shows that more emphasis is needed for melanoma screening and awareness in skin of color populations to improve survival outcomes,²⁴ and this begins with educating not only future dermatologists but all future physicians as well. The failure to include photographs of skin of color patients in discussions or lectures regarding cutaneous malignancies may serve to further perpetuate the harmful misperception that individuals with skin of color are unaffected by skin cancer.^25,26

Analysis of Skin of Color Photographs in Infectious Disease Lectures—In addition, lectures discussing infectious etiologies were among those with the highest proportion of skin of color photographs. This relatively disproportionate representation of skin of color compared to the other lectures may contribute to the development of harmful stereotypes or the stigmatization of skin of color patients. Although skin of color should continue to be represented in similar lectures, teaching faculty should remain mindful of the potential unintended impact from lectures including relatively disproportionate amounts of skin of color, particularly when other lectures may have sparse to absent representation of skin of color.

More Photographs Available for Education—Overall, our findings may help to inform changes to preclinical dermatology medical education at other institutions to create more inclusive and representative curricula for skin of color patients. The ability of instructors to provide visual representation of various dermatologic conditions may be limited by the photographs available in certain textbooks with few examples of patients with skin of color; however, concerns regarding the lack of skin of color representation in dermatology training is not a novel discussion.¹⁷ Although it is the responsibility of all dermatologists to advocate for the inclusion of skin of color, many dermatologists of color have been leading the way in this movement for decades, publishing several textbooks to document various skin conditions in those with darker skin types and discuss unique considerations for patients with skin of color.^27-29 Images from these textbooks can be utilized by programs to increase representation of skin of color in dermatology training. There also are multiple expanding online dermatologic databases, such as VisualDx, with an increasing focus on skin of color patients, some of which allow users to filter images by degree of skin pigmentation.³⁰ Moreover, instructors also can work to diversify their curricula by highlighting more of the SOCS conditions of importance to skin of color patients, which have since been renamed and highlighted on the Patient Dermatology Education section of the SOCS website.²⁰ These conditions, while not completely comprehensive, provide a useful starting point for medical educators to reevaluate for potential areas of improvement and inclusion.

There are several potential strategies that can be used to better represent skin of color in dermatologic preclinical medical education, including increasing awareness, especially among dermatology teaching faculty, of existing disparities in the representation of skin of color in the preclinical curricula. Additionally, all dermatology teaching materials could be reviewed at the department level prior to being disseminated to medical students to assess for instances in which skin of color could be prioritized for discussion or varying disease presentations in skin of color could be demonstrated. Finally, teaching faculty may consider photographing more clinical images of their skin of color patients to further develop a catalog of diverse images that can be used to teach students.

Study Limitations—Our study was unable to account for verbal discussion of skin of color not otherwise denoted or captured in lecture slides. Additional limitations include the utilization of Fitzpatrick skin types to describe and differentiate varying skin tones, as the Fitzpatrick scale originally was developed as a method to describe an individual’s response to UV exposure.¹⁹ The inability to further delineate the representation of darker skin types, such as those that may be classified as Fitzpatrick skin types V or VI,¹⁹ compared to those with lighter skin of color also was a limiting factor. This study was unable to assess for discussion of other common conditions affecting skin of color patients that were not listed as one of the priority conditions by SOCS. Photographs that were designated as indeterminate were difficult to elucidate as skin of color; however, it is possible that instructors may have verbally described these images as skin of color during lectures. Nonetheless, it may be beneficial for learners if teaching faculty were to clearly label instances where skin of color patients are shown or when notable differences are present.

Future studies would benefit from the inclusion of audio data from lectures, syllabi, and small group teaching materials from preclinical courses to more accurately assess representation of skin of color in dermatology training. Additionally, future studies also may expand to include images from lectures of overlapping clinical specialties, particularly infectious disease and rheumatology, to provide a broader assessment of skin of color exposure. Furthermore, repeat assessment may be beneficial to assess the longitudinal effectiveness of curricular changes at the institutions included in this study, comparing older lectures to more recent, updated lectures. This study also may be replicated at other medical schools to allow for wider comparison of curricula.

Acknowledgment—The authors wish to thank the institutions that offered and agreed to participate in this study with the hopes of improving medical education.

A ccording to the US Census Bureau, more than half of all Americans are projected to belong to a minority group, defined as any group other than non-Hispanic White alone, by 2044. ¹ Consequently, the United States rapidly is becoming a country in which the majority of citizens will have skin of color. Individuals with skin of color are of diverse ethnic backgrounds and include people of African, Latin American, Native American, Pacific Islander, and Asian descent, as well as interethnic backgrounds. ² Throughout the country, dermatologists along with primary care practitioners may be confronted with certain cutaneous conditions that have varying disease presentations or processes in patients with skin of color. It also is important to note that racial categories are socially rather than biologically constructed, and the term skin of color includes a wide variety of diverse skin types. Nevertheless, the current literature thoroughly supports unique pathophysiologic differences in skin of color as well as variations in disease manifestation compared to White patients. ^3-5 For example, the increased lability of melanosomes in skin of color patients, which increases their risk for postinflammatory hyperpigmentation, has been well documented. ^5-7 There are various dermatologic conditions that also occur with higher frequency and manifest uniquely in people with darker, more pigmented skin, ^7-9 and dermatologists, along with primary care physicians, should feel prepared to recognize and address them.

Extensive evidence also indicates that there are unique aspects to consider while managing certain skin diseases in patients with skin of color.^8,10,11 Consequently, as noted on the Skin of Color Society (SOCS) website, “[a]n increase in the body of dermatological literature concerning skin of color as well as the advancement of both basic science and clinical investigational research is necessary to meet the needs of the expanding skin of color population.”² In the meantime, current knowledge regarding cutaneous conditions that diversely or disproportionately affect skin of color should be actively disseminated to physicians in training. Although patients with skin of color should always have access to comprehensive care and knowledgeable practitioners, the current changes in national and regional demographics further underscore the need for a more thorough understanding of skin of color with regard to disease pathogenesis, diagnosis, and treatment.

Several studies have found that medical students in the United States are minimally exposed to dermatology in general compared to other clinical specialties,^12-14 which can easily lead to the underrecognition of disorders that may uniquely or disproportionately affect individuals with pigmented skin. Recent data showed that medical schools typically required fewer than 10 hours of dermatology instruction,¹² and on average, dermatologic training made up less than 1% of a medical student’s undergraduate medical education.^13,15,16 Consequently, less than 40% of primary care residents felt that their medical school curriculum adequately prepared them to manage common skin conditions.¹⁴ Although not all physicians should be expected to fully grasp the complexities of skin of color and its diagnostic and therapeutic implications, both practicing and training dermatologists have acknowledged a lack of exposure to skin of color. In one study, approximately 47% of dermatologists and dermatology residents reported that their medical training (medical school and/or residency) was inadequate in training them on skin conditions in Black patients. Furthermore, many who felt their training was lacking in skin of color identified the need for greater exposure to Black patients and training materials.¹⁵ The absence of comprehensive medical education regarding skin of color ultimately can be a disadvantage for both practitioners and patients, resulting in poorer outcomes. Furthermore, underrepresentation of skin of color may persist beyond undergraduate and graduate medical education. There also is evidence to suggest that noninclusion of skin of color pervades foundational dermatologic educational resources, including commonly used textbooks as well as continuing medical education disseminated at national conferences and meetings.¹⁷ Taken together, these findings highlight the need for more diverse and representative exposure to skin of color throughout medical training, which begins with a diverse inclusive undergraduate medical education in dermatology.

The objective of this study was to determine if the preclinical dermatology curriculum at 3 US medical schools provided adequate representation of skin of color patients in their didactic presentation slides.

Methods

Participants—Three US medical schools, a blend of private and public medical schools located across different geographic boundaries, agreed to participate in the study. All 3 institutions were current members of the American Medical Association (AMA) Accelerating Change in Medical Education consortium, whose primary goal is to create the medical school of the future and transform physician training.¹⁸ All 32 member institutions of the AMA consortium were contacted to request their participation in the study. As part of the consortium, these institutions have vowed to collectively work to develop and share the best models for educational advancement to improve care for patients, populations, and communities¹⁸ and would expectedly provide a more racially and ethnically inclusive curriculum than an institution not accountable to a group dedicated to identifying the best ways to deliver care for increasingly diverse communities.

Data Collection—Lectures were included if they were presented during dermatology preclinical courses in the 2015 to 2016 academic year. An uninvolved third party removed the names and identities of instructors to preserve anonymity. Two independent coders from different institutions extracted the data—lecture title, total number of clinical and histologic images, and number of skin of color images—from each of the anonymized lectures using a standardized coding form. We documented differences in skin of color noted in lectures and the disease context for the discussed differences, such as variations in clinical presentation, disease process, epidemiology/risk, and treatment between different skin phenotypes or ethnic groups. Photographs in which the coders were unable to differentiate whether the patient had skin of color were designated as indeterminate or unclear. Photographs appearing to represent Fitzpatrick skin types IV, V, and VI¹⁹ were categorically designated as skin of color, and those appearing to represent Fitzpatrick skin types I and II were described as not skin of color; however, images appearing to represent Fitzpatrick skin type III often were classified as not skin of color or indeterminate and occasionally skin of color. The Figure shows examples of images classified as skin of color, indeterminate, and not skin of color. Photographs often were classified as indeterminate due to poor lighting, close-up view photographs, or highlighted pathology obscuring the surrounding skin. We excluded duplicate photographs and histologic images from the analyses.

We also reviewed 19 conditions previously highlighted by the SOCS as areas of importance to skin of color patients.²⁰ The coders tracked how many of these conditions were noted in each lecture. Duplicate discussion of these conditions was not included in the analyses. Any discrepancies between coders were resolved through additional slide review and discussion. The final coded data with the agreed upon changes were used for statistical analyses. Recent national demographic data from the US Census Bureau in 2019 describe approximately 39.9% of the population as belonging to racial/ethnic groups other than non-Hispanic/Latinx White.²¹ Consequently, the standard for adequate representation for skin of color photographs was set at 35% for the purpose of this study.

Across all 3 institutions included in the study, the proportion of the total number of clinical photographs showing skin of color was 16% (290/1812). Eight percent of the total photographs (145/1812) were noted to be indeterminate (Table). For institution 1, 23.6% of photographs (155/658) showed skin of color, and 12.6% (83/658) were indeterminate. For institution 2, 13.1% (76/578) showed skin of color and 7.8% (45/578) were indeterminate. For institution 3, 10.2% (59/576) showed skin of color and 3% (17/576) were indeterminate.

Institutions 1, 2, and 3 had 18, 8, and 17 total dermatology lectures, respectively. Of the 19 conditions designated as areas of importance to skin of color patients by the SOCS, 16 (84.2%) were discussed by institution 1, 11 (57.9%) by institution 2, and 9 (47.4%) by institution 3 (eTable 1). Institution 3 did not include photographs of skin of color patients in its acne, psoriasis, or cutaneous malignancy lectures. Institution 1 also did not include any skin of color patients in its malignancy lecture. Lectures that focused on pigmentary disorders, atopic dermatitis, infectious conditions, and benign cutaneous neoplasms were more likely to display photographs of skin of color patients; for example, lectures that discussed infectious conditions, such as superficial mycoses, herpes viruses, human papillomavirus, syphilis, and atypical mycobacterial infections, were consistently among those with higher proportions of photographs of skin of color patients.

Throughout the entire preclinical dermatology course at all 3 institutions, of 2945 lecture slides, only 24 (0.8%) unique differences were noted between skin color and non–skin of color patients, with 10 total differences noted by institution 1, 6 by institution 2, and 8 by institution 3 (Table). The majority of these differences (19/24) were related to epidemiologic differences in prevalence among varying racial/ethnic groups, with only 5 instances highlighting differences in clinical presentation. There was only a single instance that elaborated on the underlying pathophysiologic mechanisms of the discussed difference. Of all 24 unique differences discussed, 8 were related to skin cancer, 3 were related to dermatitis, and 2 were related to the difference in manifestation of erythema in patients with darker skin (eTable 2).

Comment

The results of this study demonstrated that skin of color is underrepresented in the preclinical dermatology curriculum at these 3 institutions. Although only 16% of all included clinical photographs were of skin of color, individuals with skin of color will soon represent more than half of the total US population within the next 2 decades.¹ To increase representation of skin of color patients, teaching faculty should consciously and deliberately include more photographs of skin of color patients for a wider variety of common conditions, including atopic dermatitis and psoriasis, in addition to those that tend to disparately affect skin of color patients, such as pseudofolliculitis barbae or melasma. Furthermore, they also can incorporate more detailed discussions about important differences seen in skin of color patients.

More Skin of Color Photographs in Psoriasis Lectures—At institution 3, there were no skin of color patients included in the psoriasis lecture, even though there is considerable data in the literature indicating notable differences in the clinical presentation, quality-of-life impact, and treatment of psoriasis in skin of color patients.^11,22 There are multiple nuances in psoriasis manifestation in patients with skin of color, including less-conspicuous erythema in darker skin, higher degrees of dyspigmentation, and greater body surface area involvement. For Black patients with scalp psoriasis, the impact of hair texture, styling practices, and washing frequency are additional considerations that may impact disease severity and selection of topical therapy.¹¹ The lack of inclusion of any skin of color patients in the psoriasis lecture at one institution further underscores the pressing need to prioritize communities of color in medical education.

More Skin of Color Photographs in Cutaneous Malignancy Lectures—Similarly, while a lecturer at institution 2 noted that acral lentiginous melanoma accounts for a considerable proportion of melanoma among skin of color patients,²³ there was no mention of how melanoma generally is substantially more deadly in this population, potentially due to decreased awareness and inconsistent screening.²⁴ Furthermore, at institutions 1 and 3, there were no photographs or discussion of skin of color patients during the cutaneous malignancy lectures. Evidence shows that more emphasis is needed for melanoma screening and awareness in skin of color populations to improve survival outcomes,²⁴ and this begins with educating not only future dermatologists but all future physicians as well. The failure to include photographs of skin of color patients in discussions or lectures regarding cutaneous malignancies may serve to further perpetuate the harmful misperception that individuals with skin of color are unaffected by skin cancer.^25,26

Analysis of Skin of Color Photographs in Infectious Disease Lectures—In addition, lectures discussing infectious etiologies were among those with the highest proportion of skin of color photographs. This relatively disproportionate representation of skin of color compared to the other lectures may contribute to the development of harmful stereotypes or the stigmatization of skin of color patients. Although skin of color should continue to be represented in similar lectures, teaching faculty should remain mindful of the potential unintended impact from lectures including relatively disproportionate amounts of skin of color, particularly when other lectures may have sparse to absent representation of skin of color.

More Photographs Available for Education—Overall, our findings may help to inform changes to preclinical dermatology medical education at other institutions to create more inclusive and representative curricula for skin of color patients. The ability of instructors to provide visual representation of various dermatologic conditions may be limited by the photographs available in certain textbooks with few examples of patients with skin of color; however, concerns regarding the lack of skin of color representation in dermatology training is not a novel discussion.¹⁷ Although it is the responsibility of all dermatologists to advocate for the inclusion of skin of color, many dermatologists of color have been leading the way in this movement for decades, publishing several textbooks to document various skin conditions in those with darker skin types and discuss unique considerations for patients with skin of color.^27-29 Images from these textbooks can be utilized by programs to increase representation of skin of color in dermatology training. There also are multiple expanding online dermatologic databases, such as VisualDx, with an increasing focus on skin of color patients, some of which allow users to filter images by degree of skin pigmentation.³⁰ Moreover, instructors also can work to diversify their curricula by highlighting more of the SOCS conditions of importance to skin of color patients, which have since been renamed and highlighted on the Patient Dermatology Education section of the SOCS website.²⁰ These conditions, while not completely comprehensive, provide a useful starting point for medical educators to reevaluate for potential areas of improvement and inclusion.

There are several potential strategies that can be used to better represent skin of color in dermatologic preclinical medical education, including increasing awareness, especially among dermatology teaching faculty, of existing disparities in the representation of skin of color in the preclinical curricula. Additionally, all dermatology teaching materials could be reviewed at the department level prior to being disseminated to medical students to assess for instances in which skin of color could be prioritized for discussion or varying disease presentations in skin of color could be demonstrated. Finally, teaching faculty may consider photographing more clinical images of their skin of color patients to further develop a catalog of diverse images that can be used to teach students.

Study Limitations—Our study was unable to account for verbal discussion of skin of color not otherwise denoted or captured in lecture slides. Additional limitations include the utilization of Fitzpatrick skin types to describe and differentiate varying skin tones, as the Fitzpatrick scale originally was developed as a method to describe an individual’s response to UV exposure.¹⁹ The inability to further delineate the representation of darker skin types, such as those that may be classified as Fitzpatrick skin types V or VI,¹⁹ compared to those with lighter skin of color also was a limiting factor. This study was unable to assess for discussion of other common conditions affecting skin of color patients that were not listed as one of the priority conditions by SOCS. Photographs that were designated as indeterminate were difficult to elucidate as skin of color; however, it is possible that instructors may have verbally described these images as skin of color during lectures. Nonetheless, it may be beneficial for learners if teaching faculty were to clearly label instances where skin of color patients are shown or when notable differences are present.

Future studies would benefit from the inclusion of audio data from lectures, syllabi, and small group teaching materials from preclinical courses to more accurately assess representation of skin of color in dermatology training. Additionally, future studies also may expand to include images from lectures of overlapping clinical specialties, particularly infectious disease and rheumatology, to provide a broader assessment of skin of color exposure. Furthermore, repeat assessment may be beneficial to assess the longitudinal effectiveness of curricular changes at the institutions included in this study, comparing older lectures to more recent, updated lectures. This study also may be replicated at other medical schools to allow for wider comparison of curricula.

Acknowledgment—The authors wish to thank the institutions that offered and agreed to participate in this study with the hopes of improving medical education.

This fall, the Supreme Court of the United States (SCOTUS) will announce when they will hear oral arguments for Dobbs v Jackson Women’s Health Organization. The court will examine a Mississippi law, known as the “Gestational Age Act,” originally passed in 2018, that sought to “limit abortions to fifteen weeks’ gestation except in a medical emergency or in cases of severe fetal abnormality.”¹ This sets the stage for SCOTUS to make a major ruling on abortion, one which could affirm or upend landmark decisions and nearly 50 years of abortion legislative precedent. Additionally, SCOTUS’ recent decision to not intervene on Texas’ Senate Bill 8 (SB8), which essentially bans all abortions after 6 weeks’ gestational age, may foreshadow how this case will be decided. The current abortion restrictions in Texas and the implications of SB8 will be discussed in a forthcoming column.

SCOTUS and abortion rights

The decision to hear this case comes on the heels of another recent decision regarding a Louisiana law in June Medical Services v Russo. This case examined Louisiana Act 620, which would have required physicians to have hospital admitting privileges within 30 miles of where they provide abortion services.² The law was deemed constitutionally invalid, with the majority noting the law would have drastically burdened a woman’s right to access abortion services. The Court ruled similarly in 2016 in Whole Women’s Health (WWH) v Hellerstedt, in which WWH challenged Texas House Bill 2, a nearly identical law requiring admitting privileges for abortion care providers. In both of these cases, SCOTUS pointed to precedent set by Southeastern Pennsylvania v Casey, which established that it is unconstitutional for a state to create an “undue burden” on a woman’s right to abortion prior to fetal viability.³ The precedent to this, Roe v Wade, and 5 decades of abortion legislation set may be upended by a SCOTUS decision this next term.

Dobbs v Jackson

On March 19, 2018, Mississippi enacted the “Gestational Age Act” into law. The newly enacted law would limit abortions to 15 weeks’ gestation except in a medical emergency or in cases of severe fetal anomalies. Jackson Women’s Health Organization, the only licensed abortion provider in the state, challenged the constitutionality of the law with legal support from Center for Reproductive Rights (CRR). The US District Court for the Southern District of Mississippi granted summary judgement in favor of the clinic and placed an injunction on the law’s enforcement. The state appealed to the Fifth Circuit Court of Appeals, which upheld the district court decision in a 3-0 decision in November 2019. Mississippi appealed to the Supreme Court, with their petition focusing on multiple questions from the appeals process. After repeatedly rescheduling the case, and multiple reviews in conference, SCOTUS agreed to hear the case. Most recently, the state has narrowed its argument, changing course, and attacking Roe v Wade directly. In a brief submitted in July 2021, the state argues the court should hold that all pre-viability prohibitions on elective abortions are constitutional.

Interestingly, during this time the Mississippi legislature also passed a law, House Bill 2116, also known as the “fetal heartbeat bill,” banning abortion with gestational ages after detection of a fetal heartbeat. This was also challenged, deemed unconstitutional, and affirmed on appeal by the Fifth US Circuit Court.

While recent challenges have focused on the “undue burden” state laws placed on those trying to access abortion care, this case will bring the issue of “viability” and gestational age limits to the forefront.^4,5 In addition to Roe v Wade, the Court will have the opportunity to reexamine other relevant precedent, such as Southeastern Pennsylvania v Casey, in considering the most recent arguments of the state. In this most recent brief, the state argues that the Court should, “reject viability as a barrier to prohibiting elective abortions” and that a “viability rule has no constitutional basis.” The state goes on to argue the “Constitution does not protect a right to abortion or limit States’ authority to restrict it.”⁶ The language and tone in this brief are more direct and aggressive than the states’ petition submitted last June.

However, the composition of the Court is different than in the past. This case will be argued with Justice Amy Coney Barrett seated in place of Justice Ruth Bader Ginsburg, who was a strong advocate for women’s rights.⁷ She joins Justices Neil Gorsuch and Brett Kavanaugh, also appointed by President Donald Trump and widely viewed as conservative judges, tipping the scales to a more conservative Supreme Court. This case will also be argued in a polarized political environment.^8,9 Given the conservative Supreme Court in the setting of an increasingly politically charged environment, reproductive right advocates are understandably worried that members of the anti-abortion movement view this as an opportunity to weaken or remove federal constitutional protections for abortion.

Continue to: Potential outcome of Dobbs v Jackson...

Should SCOTUS choose to rule in favor of Mississippi, it could severely weaken, or even overturn Roe v Wade. This would leave a legal path for states with pre-Roe abortion bans and currently unenforced post-Roe bans to take effect. These “trigger” laws are bans or severe restrictions on abortion providers and patients intended to take effect if Roe were to be overturned. Alternatively, the Court may overturn Southeastern Pennsylvania v Casey, but maintain Roe v Wade, essentially leaving the regulation of pre-viability abortion care to individual states. Currently 21 states have laws that would restrict the legal status of abortion.¹⁰ In addition, state legislatures are aggressively introducing abortion restrictions. As of June 2021, there have been 561 abortion restrictions, including 165 abortion bans, introduced across 47 states, putting 2021 on course to be the most devastating anti-abortion state legislative session in decades.¹¹

The damage caused by such restriction on abortion care would be significant. It would block or push access out of reach for many. The negative effects of such legislative action would most heavily burden those already marginalized by systemic, structural inequalities including those of low socioeconomic status, people of color, young people, those in rural communities, and members of the LGBTQ community. The medical community has long recognized the harm caused by restricting access to abortion care. Restriction of access to safe abortion care paradoxically has been shown not to decrease the incidence of abortion, but rather increases the number of unsafe abortions.¹² The American College of Obstetricians and Gynecologists (ACOG) acknowledge “individuals require access to safe, legal abortion” and that this represents “a necessary component for comprehensive health care.”^13,14 They joined the American Medical Association and other professional groups in a 2019 amicus brief to SCOTUS opposing restrictions on abortion access.¹⁵ In addition, government laws restricting access to abortion care undermine the fundamental relationship between a person and their physician, limiting a physician’s obligation to honor patient autonomy and provide appropriate medical care.

By taking up the question whether all pre-viability bans on elective abortions violate the Constitution, SCOTUS is indicating a possible willingness to revisit the central holding of abortion jurisprudence. Their decision regarding this case will likely be the most significant ruling regarding the legal status of abortion care in decades, and will significantly affect the delivery of abortion care in the future.

Action items

• Reach out to your representatives to support the Women’s Health Protection Act, an initiative introduced to Congress to protect access to abortion care. If you reside in a state where your federal representatives support the Women’s Health Protection Act, reach out to friends and colleagues in states without supportive elected officials and ask them to call their representatives and ask them to support the bill.
• Get involved with local grassroots groups fighting to protect abortion access.
• Continue to speak out against laws and policies designed to limit access to safe abortion care.
• Connect with your local ACOG chapter for more ways to become involved.
• As always, make sure you are registered to vote, and exercise your right whenever you can.

This fall, the Supreme Court of the United States (SCOTUS) will announce when they will hear oral arguments for Dobbs v Jackson Women’s Health Organization. The court will examine a Mississippi law, known as the “Gestational Age Act,” originally passed in 2018, that sought to “limit abortions to fifteen weeks’ gestation except in a medical emergency or in cases of severe fetal abnormality.”¹ This sets the stage for SCOTUS to make a major ruling on abortion, one which could affirm or upend landmark decisions and nearly 50 years of abortion legislative precedent. Additionally, SCOTUS’ recent decision to not intervene on Texas’ Senate Bill 8 (SB8), which essentially bans all abortions after 6 weeks’ gestational age, may foreshadow how this case will be decided. The current abortion restrictions in Texas and the implications of SB8 will be discussed in a forthcoming column.

SCOTUS and abortion rights

The decision to hear this case comes on the heels of another recent decision regarding a Louisiana law in June Medical Services v Russo. This case examined Louisiana Act 620, which would have required physicians to have hospital admitting privileges within 30 miles of where they provide abortion services.² The law was deemed constitutionally invalid, with the majority noting the law would have drastically burdened a woman’s right to access abortion services. The Court ruled similarly in 2016 in Whole Women’s Health (WWH) v Hellerstedt, in which WWH challenged Texas House Bill 2, a nearly identical law requiring admitting privileges for abortion care providers. In both of these cases, SCOTUS pointed to precedent set by Southeastern Pennsylvania v Casey, which established that it is unconstitutional for a state to create an “undue burden” on a woman’s right to abortion prior to fetal viability.³ The precedent to this, Roe v Wade, and 5 decades of abortion legislation set may be upended by a SCOTUS decision this next term.

Dobbs v Jackson

On March 19, 2018, Mississippi enacted the “Gestational Age Act” into law. The newly enacted law would limit abortions to 15 weeks’ gestation except in a medical emergency or in cases of severe fetal anomalies. Jackson Women’s Health Organization, the only licensed abortion provider in the state, challenged the constitutionality of the law with legal support from Center for Reproductive Rights (CRR). The US District Court for the Southern District of Mississippi granted summary judgement in favor of the clinic and placed an injunction on the law’s enforcement. The state appealed to the Fifth Circuit Court of Appeals, which upheld the district court decision in a 3-0 decision in November 2019. Mississippi appealed to the Supreme Court, with their petition focusing on multiple questions from the appeals process. After repeatedly rescheduling the case, and multiple reviews in conference, SCOTUS agreed to hear the case. Most recently, the state has narrowed its argument, changing course, and attacking Roe v Wade directly. In a brief submitted in July 2021, the state argues the court should hold that all pre-viability prohibitions on elective abortions are constitutional.

Interestingly, during this time the Mississippi legislature also passed a law, House Bill 2116, also known as the “fetal heartbeat bill,” banning abortion with gestational ages after detection of a fetal heartbeat. This was also challenged, deemed unconstitutional, and affirmed on appeal by the Fifth US Circuit Court.

While recent challenges have focused on the “undue burden” state laws placed on those trying to access abortion care, this case will bring the issue of “viability” and gestational age limits to the forefront.^4,5 In addition to Roe v Wade, the Court will have the opportunity to reexamine other relevant precedent, such as Southeastern Pennsylvania v Casey, in considering the most recent arguments of the state. In this most recent brief, the state argues that the Court should, “reject viability as a barrier to prohibiting elective abortions” and that a “viability rule has no constitutional basis.” The state goes on to argue the “Constitution does not protect a right to abortion or limit States’ authority to restrict it.”⁶ The language and tone in this brief are more direct and aggressive than the states’ petition submitted last June.

However, the composition of the Court is different than in the past. This case will be argued with Justice Amy Coney Barrett seated in place of Justice Ruth Bader Ginsburg, who was a strong advocate for women’s rights.⁷ She joins Justices Neil Gorsuch and Brett Kavanaugh, also appointed by President Donald Trump and widely viewed as conservative judges, tipping the scales to a more conservative Supreme Court. This case will also be argued in a polarized political environment.^8,9 Given the conservative Supreme Court in the setting of an increasingly politically charged environment, reproductive right advocates are understandably worried that members of the anti-abortion movement view this as an opportunity to weaken or remove federal constitutional protections for abortion.

Continue to: Potential outcome of Dobbs v Jackson...

Should SCOTUS choose to rule in favor of Mississippi, it could severely weaken, or even overturn Roe v Wade. This would leave a legal path for states with pre-Roe abortion bans and currently unenforced post-Roe bans to take effect. These “trigger” laws are bans or severe restrictions on abortion providers and patients intended to take effect if Roe were to be overturned. Alternatively, the Court may overturn Southeastern Pennsylvania v Casey, but maintain Roe v Wade, essentially leaving the regulation of pre-viability abortion care to individual states. Currently 21 states have laws that would restrict the legal status of abortion.¹⁰ In addition, state legislatures are aggressively introducing abortion restrictions. As of June 2021, there have been 561 abortion restrictions, including 165 abortion bans, introduced across 47 states, putting 2021 on course to be the most devastating anti-abortion state legislative session in decades.¹¹

The damage caused by such restriction on abortion care would be significant. It would block or push access out of reach for many. The negative effects of such legislative action would most heavily burden those already marginalized by systemic, structural inequalities including those of low socioeconomic status, people of color, young people, those in rural communities, and members of the LGBTQ community. The medical community has long recognized the harm caused by restricting access to abortion care. Restriction of access to safe abortion care paradoxically has been shown not to decrease the incidence of abortion, but rather increases the number of unsafe abortions.¹² The American College of Obstetricians and Gynecologists (ACOG) acknowledge “individuals require access to safe, legal abortion” and that this represents “a necessary component for comprehensive health care.”^13,14 They joined the American Medical Association and other professional groups in a 2019 amicus brief to SCOTUS opposing restrictions on abortion access.¹⁵ In addition, government laws restricting access to abortion care undermine the fundamental relationship between a person and their physician, limiting a physician’s obligation to honor patient autonomy and provide appropriate medical care.

By taking up the question whether all pre-viability bans on elective abortions violate the Constitution, SCOTUS is indicating a possible willingness to revisit the central holding of abortion jurisprudence. Their decision regarding this case will likely be the most significant ruling regarding the legal status of abortion care in decades, and will significantly affect the delivery of abortion care in the future.

Action items

• Reach out to your representatives to support the Women’s Health Protection Act, an initiative introduced to Congress to protect access to abortion care. If you reside in a state where your federal representatives support the Women’s Health Protection Act, reach out to friends and colleagues in states without supportive elected officials and ask them to call their representatives and ask them to support the bill.
• Get involved with local grassroots groups fighting to protect abortion access.
• Continue to speak out against laws and policies designed to limit access to safe abortion care.
• Connect with your local ACOG chapter for more ways to become involved.
• As always, make sure you are registered to vote, and exercise your right whenever you can.

This fall, the Supreme Court of the United States (SCOTUS) will announce when they will hear oral arguments for Dobbs v Jackson Women’s Health Organization. The court will examine a Mississippi law, known as the “Gestational Age Act,” originally passed in 2018, that sought to “limit abortions to fifteen weeks’ gestation except in a medical emergency or in cases of severe fetal abnormality.”¹ This sets the stage for SCOTUS to make a major ruling on abortion, one which could affirm or upend landmark decisions and nearly 50 years of abortion legislative precedent. Additionally, SCOTUS’ recent decision to not intervene on Texas’ Senate Bill 8 (SB8), which essentially bans all abortions after 6 weeks’ gestational age, may foreshadow how this case will be decided. The current abortion restrictions in Texas and the implications of SB8 will be discussed in a forthcoming column.

SCOTUS and abortion rights

The decision to hear this case comes on the heels of another recent decision regarding a Louisiana law in June Medical Services v Russo. This case examined Louisiana Act 620, which would have required physicians to have hospital admitting privileges within 30 miles of where they provide abortion services.² The law was deemed constitutionally invalid, with the majority noting the law would have drastically burdened a woman’s right to access abortion services. The Court ruled similarly in 2016 in Whole Women’s Health (WWH) v Hellerstedt, in which WWH challenged Texas House Bill 2, a nearly identical law requiring admitting privileges for abortion care providers. In both of these cases, SCOTUS pointed to precedent set by Southeastern Pennsylvania v Casey, which established that it is unconstitutional for a state to create an “undue burden” on a woman’s right to abortion prior to fetal viability.³ The precedent to this, Roe v Wade, and 5 decades of abortion legislation set may be upended by a SCOTUS decision this next term.

Dobbs v Jackson

On March 19, 2018, Mississippi enacted the “Gestational Age Act” into law. The newly enacted law would limit abortions to 15 weeks’ gestation except in a medical emergency or in cases of severe fetal anomalies. Jackson Women’s Health Organization, the only licensed abortion provider in the state, challenged the constitutionality of the law with legal support from Center for Reproductive Rights (CRR). The US District Court for the Southern District of Mississippi granted summary judgement in favor of the clinic and placed an injunction on the law’s enforcement. The state appealed to the Fifth Circuit Court of Appeals, which upheld the district court decision in a 3-0 decision in November 2019. Mississippi appealed to the Supreme Court, with their petition focusing on multiple questions from the appeals process. After repeatedly rescheduling the case, and multiple reviews in conference, SCOTUS agreed to hear the case. Most recently, the state has narrowed its argument, changing course, and attacking Roe v Wade directly. In a brief submitted in July 2021, the state argues the court should hold that all pre-viability prohibitions on elective abortions are constitutional.

Interestingly, during this time the Mississippi legislature also passed a law, House Bill 2116, also known as the “fetal heartbeat bill,” banning abortion with gestational ages after detection of a fetal heartbeat. This was also challenged, deemed unconstitutional, and affirmed on appeal by the Fifth US Circuit Court.

While recent challenges have focused on the “undue burden” state laws placed on those trying to access abortion care, this case will bring the issue of “viability” and gestational age limits to the forefront.^4,5 In addition to Roe v Wade, the Court will have the opportunity to reexamine other relevant precedent, such as Southeastern Pennsylvania v Casey, in considering the most recent arguments of the state. In this most recent brief, the state argues that the Court should, “reject viability as a barrier to prohibiting elective abortions” and that a “viability rule has no constitutional basis.” The state goes on to argue the “Constitution does not protect a right to abortion or limit States’ authority to restrict it.”⁶ The language and tone in this brief are more direct and aggressive than the states’ petition submitted last June.

However, the composition of the Court is different than in the past. This case will be argued with Justice Amy Coney Barrett seated in place of Justice Ruth Bader Ginsburg, who was a strong advocate for women’s rights.⁷ She joins Justices Neil Gorsuch and Brett Kavanaugh, also appointed by President Donald Trump and widely viewed as conservative judges, tipping the scales to a more conservative Supreme Court. This case will also be argued in a polarized political environment.^8,9 Given the conservative Supreme Court in the setting of an increasingly politically charged environment, reproductive right advocates are understandably worried that members of the anti-abortion movement view this as an opportunity to weaken or remove federal constitutional protections for abortion.

Continue to: Potential outcome of Dobbs v Jackson...

Should SCOTUS choose to rule in favor of Mississippi, it could severely weaken, or even overturn Roe v Wade. This would leave a legal path for states with pre-Roe abortion bans and currently unenforced post-Roe bans to take effect. These “trigger” laws are bans or severe restrictions on abortion providers and patients intended to take effect if Roe were to be overturned. Alternatively, the Court may overturn Southeastern Pennsylvania v Casey, but maintain Roe v Wade, essentially leaving the regulation of pre-viability abortion care to individual states. Currently 21 states have laws that would restrict the legal status of abortion.¹⁰ In addition, state legislatures are aggressively introducing abortion restrictions. As of June 2021, there have been 561 abortion restrictions, including 165 abortion bans, introduced across 47 states, putting 2021 on course to be the most devastating anti-abortion state legislative session in decades.¹¹

The damage caused by such restriction on abortion care would be significant. It would block or push access out of reach for many. The negative effects of such legislative action would most heavily burden those already marginalized by systemic, structural inequalities including those of low socioeconomic status, people of color, young people, those in rural communities, and members of the LGBTQ community. The medical community has long recognized the harm caused by restricting access to abortion care. Restriction of access to safe abortion care paradoxically has been shown not to decrease the incidence of abortion, but rather increases the number of unsafe abortions.¹² The American College of Obstetricians and Gynecologists (ACOG) acknowledge “individuals require access to safe, legal abortion” and that this represents “a necessary component for comprehensive health care.”^13,14 They joined the American Medical Association and other professional groups in a 2019 amicus brief to SCOTUS opposing restrictions on abortion access.¹⁵ In addition, government laws restricting access to abortion care undermine the fundamental relationship between a person and their physician, limiting a physician’s obligation to honor patient autonomy and provide appropriate medical care.

By taking up the question whether all pre-viability bans on elective abortions violate the Constitution, SCOTUS is indicating a possible willingness to revisit the central holding of abortion jurisprudence. Their decision regarding this case will likely be the most significant ruling regarding the legal status of abortion care in decades, and will significantly affect the delivery of abortion care in the future.

Action items

• Reach out to your representatives to support the Women’s Health Protection Act, an initiative introduced to Congress to protect access to abortion care. If you reside in a state where your federal representatives support the Women’s Health Protection Act, reach out to friends and colleagues in states without supportive elected officials and ask them to call their representatives and ask them to support the bill.
• Get involved with local grassroots groups fighting to protect abortion access.
• Continue to speak out against laws and policies designed to limit access to safe abortion care.
• Connect with your local ACOG chapter for more ways to become involved.
• As always, make sure you are registered to vote, and exercise your right whenever you can.

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.