Steven D. Daveluy, MD

Educational organizations across several specialties, including internal medicine and obstetrics and gynecology, have formal surveys¹; however, the field of dermatology has been without one. This study aimed to establish a formal survey for dermatology program directors (PDs) and clinician-educators. Because the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Dermatology surveys do not capture all metrics relevant to dermatology residency educators, an annual survey for our specialty may be helpful to compare dermatology-specific data among programs. Responses could provide context and perspective to faculty and residents who respond to the ACGME annual survey, as our Association of Professors of Dermatology (APD) survey asks more in-depth questions, such as how often didactics occur and who leads them. Resident commute time and faculty demographics and training also are covered. Current ad hoc surveys disseminated through listserves of various medical associations contain overlapping questions and reflect relatively low response rates; dermatology PDs may benefit from a survey with a high response rate to which they can contribute future questions and topics that reflect recent trends and current needs in graduate medical education. As future surveys are administered, the results can be captured in a centralized database accessible by dermatology PDs.

Methods

A survey of PDs from 141 ACGME-accredited dermatology residency programs was conducted by the Residency Program Director Steering Committee of the APD from November 2022 to January 2023 using a prevalidated questionnaire. Personalized survey links were created and sent individually to each PD’s email listed in the ACGME accreditation data system. All survey responses were captured anonymously, with a number assigned to keep de-identified responses separate and organized. The survey consisted of 137 survey questions addressing topics that included program characteristics, PD demographics, the impact of the COVID-19 pandemic on clinical rotation and educational conferences, available resident resources, quality improvement, clinical and didactic instruction, research content, diversity and inclusion, wellness, professionalism, evaluation systems, and graduate outcomes.

Data were collected using Qualtrics survey tools. After removing duplicate and incomplete surveys, data were analyzed using Qualtrics reports and Microsoft Excel for data plotting, averages, and range calculations.

Results

One hundred forty-one personalized survey links were created and sent individually to each program’s filed email obtained from the APD listserv. Fifty-three responses were recorded after removing duplicate or incomplete surveys (38% [53/141] response rate). As of May 2023, there were 144 ACGME-accredited dermatology residency programs due to 3 newly accredited programs in 2022-2023 academic year, which were not included in our survey population.

Program Characteristics—Forty-four respondents (83%) were from a university-based program. Fifty respondents (94%) were from programs that were ACGME accredited prior to 2020, while 3 programs (6%) were American Osteopathic Association accredited prior to singular accreditation. Seventy-one percent (38/53) of respondents had 1 or more associate PDs.

PD Demographics—Eighty-seven percent (45/52) of PDs who responded to the survey graduated from a US allopathic medical school (MD), 10% (5/52) graduated from a US osteopathic medical school (DO), and 4% (2/52) graduated from an international medical school. Seventy-four percent (35/47) of respondents were White, 17% (8/47) were Asian, and 2% (1/47) were Black or African American; this data was not provided for 4 respondents. Forty-eight percent (23/48) of PDs identified as cisgender man, 48% (23/48) identified as cisgender woman, and 4% (2/48) preferred not to answer. Eighty-one percent (38/47) of PDs identified as heterosexual or straight, 15% (7/47) identified as gay or lesbian, and 4% (2/47) preferred not to answer.

Impact of COVID-19 Pandemic on Residency Training—Due to the COVID-19 pandemic, 88% (45/51) of respondents incorporated telemedicine into the resident clinical rotation schedule. Moving forward, 75% (38/51) of respondents indicated that their programs plan to continue to incorporate telemedicine into the rotation schedule. Based on 50 responses, the average of educational conferences that became virtual at the start of the COVID-19 pandemic was 87%; based on 46 responses, the percentage of educational conferences that will remain virtual moving forward is 46%, while 90% (46/51) of respondents indicated that their programs plan to use virtual conferences in some capacity moving forward. Seventy-three percent (37/51) of respondents indicated that they plan to use virtual interviews as part of residency recruitment moving forward.

Available Resources—Twenty-four percent (11/46) of respondents indicated that residents in their program do not get protected time or time off for CORE examinations. Seventy-five percent (33/44) of PDs said their program provides funding for residents to participate in board review courses. The chief residents at 63% (31/49) of programs receive additional compensation, and 69% (34/49) provide additional administrative time to chief residents. Seventy-one percent (24/34) of PDs reported their programs have scribes for attendings, and 12% (4/34) have scribes for residents. Support staff help residents with callbacks and in-basket messages according to 76% (35/46) of respondents. The majority (98% [45/46]) of PDs indicated that residents follow-up on results and messages from patients seen in resident clinics, and 43% (20/46) of programs have residents follow-up with patients seen in faculty clinics. Only 15% (7/46) of PDs responded they have schedules with residents dedicated to handle these tasks. According to respondents, 33% (17/52) have residents who are required to travel more than 25 miles to distant clinical sites. Of them, 35% (6/17) provide accommodations.

Quality Improvement—Seventy-one percent (35/49) of respondents indicated their department has a quality improvement/patient safety team or committee, and 94% (33/35) of these teams include residents. A lecture series on quality improvement and patient safety is offered at 67% (33/49) of the respondents’ programs, while morbidity and mortality conferences are offered in 73% (36/49).

Clinical Instruction—Our survey asked PDs how many months each residency year spends on a certain rotational service. Based on 46 respondents, the average number of months dedicated to medical dermatology is 7, 5, and 6 months for postgraduate year (PGY) 2, PGY3, and PGY4, respectively. The average number of months spent in other subspecialties is provided in the Table. On average, PGY2 residents spend 8 half-days per week seeing patients in clinic, while PGY3 and PGY4 residents see patients for 7 half-days. The median and mean number of patients staffed by a single attending per hour in teaching clinics are 6 and 5.88, respectively. Respondents indicated that residents participate in the following specialty clinics: pediatric dermatology (96% [44/46]), laser/cosmetic (87% [40/44]), high-risk skin cancer (ie, immunosuppressed/transplant patient)(65% [30/44]), pigmented lesion/melanoma (52% [24/44]), connective tissue disease (52% [24/44]), teledermatology (50% [23/44]), free clinic for homeless and/or indigent populations (48% [22/44]), contact dermatitis (43% [20/44]), skin of color (43% [20/44]), oncodermatology (41% [19/44]), and bullous disease (33% [15/44]).

Additionally, in 87% (40/46) of programs, residents participate in a dedicated inpatient consultation service. Most respondents (98% [45/46]) responded that they utilize in-person consultations with a teledermatology supplement. Fifteen percent (7/46) utilize virtual teledermatology (live video-based consultations), and 57% (26/46) utilize asynchronous teledermatology (picture-based consultations). All respondents (n=46) indicated that 0% to 25% of patient encounters involving residents are teledermatology visits. Thirty-three percent (6/18) of programs have a global health special training track, 56% (10/18) have a Specialty Training and Advanced Research/Physician-Scientist Research Training track, 28% (5/18) have a diversity training track, and 50% (9/18) have a clinician educator training track.

Didactic Instruction—Five programs have a full day per week dedicated to didactics, while 36 programs have at least one half-day per week for didactics. On average, didactics in 57% (26/46) of programs are led by faculty alone, while 43% (20/46) are led at least in part by residents or fellows.

Research Content—Fifty percent (23/46) of programs have a specific research requirement for residents beyond general ACGME requirements, and 35% (16/46) require residents to participate in a longitudinal research project over the course of residency. There is a dedicated research coordinator for resident support at 63% (29/46) of programs. Dedicated biostatistics research support is available for resident projects at 42% (19/45) of programs. Additionally, at 42% (19/45) of programs, there is a dedicated faculty member for oversight of resident research.

Diversity, Equity, and Inclusion—Seventy-three percent (29/40) of programs have special diversity, equity, and inclusion programs or meetings specific to residency, 60% (24/40) have residency initiatives, and 55% (22/40) have a residency diversity committee. Eighty-six percent (42/49) of respondents strongly agreed that their current residents represent diverse ethnic and racial backgrounds (ie, >15% are not White). eTable 1 shows PD responses to this statement, which were stratified based on self-identified race. eTable 2 shows PD responses to the statement, “Our current residents represent an inclusion of gender/sexual orientation,” which were stratified based on self-identified gender identity/sexual orientation. Lastly, eTable 3 highlights the percentage of residents with an MD and DO degree, stratified based on PD degree.

Wellness—Forty-eight percent (20/42) of respondents indicated they are under stress and do not always have as much energy as before becoming a PD but do not feel burned out. Thirty-one percent (13/42) indicated they have 1 or more symptoms of burnout, such as emotional exhaustion. Eighty-six percent (36/42) are satisfied with their jobs overall (43% agree and 43% strongly agree [18/42 each]).

Evaluation System—Seventy-five percent (33/44) of programs deliver evaluations of residents by faculty online, 86% (38/44) of programs have PDs discuss evaluations in-person, and 20% (9/44) of programs have faculty evaluators discuss evaluations in-person. Seventy-seven percent (34/44) of programs have formal faculty-resident mentor-mentee programs. Clinical competency committee chair positions are filled by PDs, assistant PDs, or core faculty members 47%, 38%, and 16% of the time, respectively.

Graduation Outcomes of PGY4 Residents—About 28% (55/199) of graduating residents applied to a fellowship position, with the majority (15% [29/55]) matching into Mohs micrographic surgery and dermatologic oncology (MSDO) fellowships. Approximately 5% (9/199) and 4% (7/199) of graduates matched into dermatopathology and pediatric dermatology, respectively. The remaining 5% (10/199) of graduating residents applied to a fellowship but did not match. The majority (45% [91/199]) of residency graduates entered private practice after graduation. Approximately 21% (42/199) of graduating residents chose an academic practice with 17% (33/199), 2% (4/199), and 2% (3/199) of those positions being full-time, part-time, and adjunct, respectively.

Comment

The first annual APD survey is a novel data source and provides opportunities for areas of discussion and investigation. Evaluating the similarities and differences among dermatology residency programs across the United States can strengthen individual programs through collaboration and provide areas of cohesion among programs.

Diversity of PDs—An important area of discussion is diversity and PD demographics. Although DO students make up 1 in 4 US graduating medical students, they are not interviewed or ranked as often as MD students.² Diversity in PD race and ethnicity may be worthy of investigation in future studies, as match rates and recruitment of diverse medical school applicants may be impacted by these demographics.

Continued Use of Telemedicine in Training—Since 2020, the benefits of virtual residency recruitment have been debated among PDs across all medical specialties. Points in favor of virtual interviews include cost savings for programs and especially for applicants, as well as time efficiency, reduced burden of travel, and reduced carbon footprint. A problem posed by virtual interviews is that candidates are unable to fully learn institutional cultures and social environments of the programs.³ Likewise, telehealth was an important means of clinical teaching for residents during the height of the COVID-19 pandemic, with benefits that included cost-effectiveness and reduction of disparities in access to dermatologic care.⁴ Seventy-five percent (38/51) of PDs indicated that their program plans to include telemedicine in resident clinical rotation moving forward.

Resources Available—Our survey showed that resources available for residents, delivery of lectures and program time allocated to didactics, protected academic or study time for residents, and allocation of program time for CORE examinations are highly variable across programs. This could inspire future studies to be done to determine the differences in success of the resident on CORE examinations and in digesting material.

Postgraduate Career Plans and Fellowship Matches—Residents of programs that have a home MSDO fellowship are more likely to successfully match into a MSDO fellowship.⁵ Based on this survey, approximately 28% of graduating residents applied to a fellowship position, with 15%, 5%, and 3% matching into desired MSDO, dermatopathology, and pediatric dermatology fellowships, respectively. Additional studies are needed to determine advantages and disadvantages that lead to residents reaching their career goals.

Limitations—Limitations of this study include a small sample size that may not adequately represent all ACGME-accredited dermatology residency programs and selection bias toward respondents who are more likely to participate in survey-based research.

Conclusion

The APD plans to continue to administer this survey on an annual basis, with updates to the content and questions based on input from PDs. This survey will continue to provide valuable information to drive collaboration among residency programs and optimize the learning experience for residents. Our hope is that the response rate will increase in coming years, allowing us to draw more generalizable conclusions. Nonetheless, the survey data allow individual dermatology residency programs to compare their specific characteristics to other programs.

Educational organizations across several specialties, including internal medicine and obstetrics and gynecology, have formal surveys¹; however, the field of dermatology has been without one. This study aimed to establish a formal survey for dermatology program directors (PDs) and clinician-educators. Because the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Dermatology surveys do not capture all metrics relevant to dermatology residency educators, an annual survey for our specialty may be helpful to compare dermatology-specific data among programs. Responses could provide context and perspective to faculty and residents who respond to the ACGME annual survey, as our Association of Professors of Dermatology (APD) survey asks more in-depth questions, such as how often didactics occur and who leads them. Resident commute time and faculty demographics and training also are covered. Current ad hoc surveys disseminated through listserves of various medical associations contain overlapping questions and reflect relatively low response rates; dermatology PDs may benefit from a survey with a high response rate to which they can contribute future questions and topics that reflect recent trends and current needs in graduate medical education. As future surveys are administered, the results can be captured in a centralized database accessible by dermatology PDs.

Methods

A survey of PDs from 141 ACGME-accredited dermatology residency programs was conducted by the Residency Program Director Steering Committee of the APD from November 2022 to January 2023 using a prevalidated questionnaire. Personalized survey links were created and sent individually to each PD’s email listed in the ACGME accreditation data system. All survey responses were captured anonymously, with a number assigned to keep de-identified responses separate and organized. The survey consisted of 137 survey questions addressing topics that included program characteristics, PD demographics, the impact of the COVID-19 pandemic on clinical rotation and educational conferences, available resident resources, quality improvement, clinical and didactic instruction, research content, diversity and inclusion, wellness, professionalism, evaluation systems, and graduate outcomes.

Data were collected using Qualtrics survey tools. After removing duplicate and incomplete surveys, data were analyzed using Qualtrics reports and Microsoft Excel for data plotting, averages, and range calculations.

Results

One hundred forty-one personalized survey links were created and sent individually to each program’s filed email obtained from the APD listserv. Fifty-three responses were recorded after removing duplicate or incomplete surveys (38% [53/141] response rate). As of May 2023, there were 144 ACGME-accredited dermatology residency programs due to 3 newly accredited programs in 2022-2023 academic year, which were not included in our survey population.

Program Characteristics—Forty-four respondents (83%) were from a university-based program. Fifty respondents (94%) were from programs that were ACGME accredited prior to 2020, while 3 programs (6%) were American Osteopathic Association accredited prior to singular accreditation. Seventy-one percent (38/53) of respondents had 1 or more associate PDs.

PD Demographics—Eighty-seven percent (45/52) of PDs who responded to the survey graduated from a US allopathic medical school (MD), 10% (5/52) graduated from a US osteopathic medical school (DO), and 4% (2/52) graduated from an international medical school. Seventy-four percent (35/47) of respondents were White, 17% (8/47) were Asian, and 2% (1/47) were Black or African American; this data was not provided for 4 respondents. Forty-eight percent (23/48) of PDs identified as cisgender man, 48% (23/48) identified as cisgender woman, and 4% (2/48) preferred not to answer. Eighty-one percent (38/47) of PDs identified as heterosexual or straight, 15% (7/47) identified as gay or lesbian, and 4% (2/47) preferred not to answer.

Impact of COVID-19 Pandemic on Residency Training—Due to the COVID-19 pandemic, 88% (45/51) of respondents incorporated telemedicine into the resident clinical rotation schedule. Moving forward, 75% (38/51) of respondents indicated that their programs plan to continue to incorporate telemedicine into the rotation schedule. Based on 50 responses, the average of educational conferences that became virtual at the start of the COVID-19 pandemic was 87%; based on 46 responses, the percentage of educational conferences that will remain virtual moving forward is 46%, while 90% (46/51) of respondents indicated that their programs plan to use virtual conferences in some capacity moving forward. Seventy-three percent (37/51) of respondents indicated that they plan to use virtual interviews as part of residency recruitment moving forward.

Available Resources—Twenty-four percent (11/46) of respondents indicated that residents in their program do not get protected time or time off for CORE examinations. Seventy-five percent (33/44) of PDs said their program provides funding for residents to participate in board review courses. The chief residents at 63% (31/49) of programs receive additional compensation, and 69% (34/49) provide additional administrative time to chief residents. Seventy-one percent (24/34) of PDs reported their programs have scribes for attendings, and 12% (4/34) have scribes for residents. Support staff help residents with callbacks and in-basket messages according to 76% (35/46) of respondents. The majority (98% [45/46]) of PDs indicated that residents follow-up on results and messages from patients seen in resident clinics, and 43% (20/46) of programs have residents follow-up with patients seen in faculty clinics. Only 15% (7/46) of PDs responded they have schedules with residents dedicated to handle these tasks. According to respondents, 33% (17/52) have residents who are required to travel more than 25 miles to distant clinical sites. Of them, 35% (6/17) provide accommodations.

Quality Improvement—Seventy-one percent (35/49) of respondents indicated their department has a quality improvement/patient safety team or committee, and 94% (33/35) of these teams include residents. A lecture series on quality improvement and patient safety is offered at 67% (33/49) of the respondents’ programs, while morbidity and mortality conferences are offered in 73% (36/49).

Clinical Instruction—Our survey asked PDs how many months each residency year spends on a certain rotational service. Based on 46 respondents, the average number of months dedicated to medical dermatology is 7, 5, and 6 months for postgraduate year (PGY) 2, PGY3, and PGY4, respectively. The average number of months spent in other subspecialties is provided in the Table. On average, PGY2 residents spend 8 half-days per week seeing patients in clinic, while PGY3 and PGY4 residents see patients for 7 half-days. The median and mean number of patients staffed by a single attending per hour in teaching clinics are 6 and 5.88, respectively. Respondents indicated that residents participate in the following specialty clinics: pediatric dermatology (96% [44/46]), laser/cosmetic (87% [40/44]), high-risk skin cancer (ie, immunosuppressed/transplant patient)(65% [30/44]), pigmented lesion/melanoma (52% [24/44]), connective tissue disease (52% [24/44]), teledermatology (50% [23/44]), free clinic for homeless and/or indigent populations (48% [22/44]), contact dermatitis (43% [20/44]), skin of color (43% [20/44]), oncodermatology (41% [19/44]), and bullous disease (33% [15/44]).

Additionally, in 87% (40/46) of programs, residents participate in a dedicated inpatient consultation service. Most respondents (98% [45/46]) responded that they utilize in-person consultations with a teledermatology supplement. Fifteen percent (7/46) utilize virtual teledermatology (live video-based consultations), and 57% (26/46) utilize asynchronous teledermatology (picture-based consultations). All respondents (n=46) indicated that 0% to 25% of patient encounters involving residents are teledermatology visits. Thirty-three percent (6/18) of programs have a global health special training track, 56% (10/18) have a Specialty Training and Advanced Research/Physician-Scientist Research Training track, 28% (5/18) have a diversity training track, and 50% (9/18) have a clinician educator training track.

Didactic Instruction—Five programs have a full day per week dedicated to didactics, while 36 programs have at least one half-day per week for didactics. On average, didactics in 57% (26/46) of programs are led by faculty alone, while 43% (20/46) are led at least in part by residents or fellows.

Research Content—Fifty percent (23/46) of programs have a specific research requirement for residents beyond general ACGME requirements, and 35% (16/46) require residents to participate in a longitudinal research project over the course of residency. There is a dedicated research coordinator for resident support at 63% (29/46) of programs. Dedicated biostatistics research support is available for resident projects at 42% (19/45) of programs. Additionally, at 42% (19/45) of programs, there is a dedicated faculty member for oversight of resident research.

Diversity, Equity, and Inclusion—Seventy-three percent (29/40) of programs have special diversity, equity, and inclusion programs or meetings specific to residency, 60% (24/40) have residency initiatives, and 55% (22/40) have a residency diversity committee. Eighty-six percent (42/49) of respondents strongly agreed that their current residents represent diverse ethnic and racial backgrounds (ie, >15% are not White). eTable 1 shows PD responses to this statement, which were stratified based on self-identified race. eTable 2 shows PD responses to the statement, “Our current residents represent an inclusion of gender/sexual orientation,” which were stratified based on self-identified gender identity/sexual orientation. Lastly, eTable 3 highlights the percentage of residents with an MD and DO degree, stratified based on PD degree.

Wellness—Forty-eight percent (20/42) of respondents indicated they are under stress and do not always have as much energy as before becoming a PD but do not feel burned out. Thirty-one percent (13/42) indicated they have 1 or more symptoms of burnout, such as emotional exhaustion. Eighty-six percent (36/42) are satisfied with their jobs overall (43% agree and 43% strongly agree [18/42 each]).

Evaluation System—Seventy-five percent (33/44) of programs deliver evaluations of residents by faculty online, 86% (38/44) of programs have PDs discuss evaluations in-person, and 20% (9/44) of programs have faculty evaluators discuss evaluations in-person. Seventy-seven percent (34/44) of programs have formal faculty-resident mentor-mentee programs. Clinical competency committee chair positions are filled by PDs, assistant PDs, or core faculty members 47%, 38%, and 16% of the time, respectively.

Graduation Outcomes of PGY4 Residents—About 28% (55/199) of graduating residents applied to a fellowship position, with the majority (15% [29/55]) matching into Mohs micrographic surgery and dermatologic oncology (MSDO) fellowships. Approximately 5% (9/199) and 4% (7/199) of graduates matched into dermatopathology and pediatric dermatology, respectively. The remaining 5% (10/199) of graduating residents applied to a fellowship but did not match. The majority (45% [91/199]) of residency graduates entered private practice after graduation. Approximately 21% (42/199) of graduating residents chose an academic practice with 17% (33/199), 2% (4/199), and 2% (3/199) of those positions being full-time, part-time, and adjunct, respectively.

Comment

The first annual APD survey is a novel data source and provides opportunities for areas of discussion and investigation. Evaluating the similarities and differences among dermatology residency programs across the United States can strengthen individual programs through collaboration and provide areas of cohesion among programs.

Diversity of PDs—An important area of discussion is diversity and PD demographics. Although DO students make up 1 in 4 US graduating medical students, they are not interviewed or ranked as often as MD students.² Diversity in PD race and ethnicity may be worthy of investigation in future studies, as match rates and recruitment of diverse medical school applicants may be impacted by these demographics.

Continued Use of Telemedicine in Training—Since 2020, the benefits of virtual residency recruitment have been debated among PDs across all medical specialties. Points in favor of virtual interviews include cost savings for programs and especially for applicants, as well as time efficiency, reduced burden of travel, and reduced carbon footprint. A problem posed by virtual interviews is that candidates are unable to fully learn institutional cultures and social environments of the programs.³ Likewise, telehealth was an important means of clinical teaching for residents during the height of the COVID-19 pandemic, with benefits that included cost-effectiveness and reduction of disparities in access to dermatologic care.⁴ Seventy-five percent (38/51) of PDs indicated that their program plans to include telemedicine in resident clinical rotation moving forward.

Resources Available—Our survey showed that resources available for residents, delivery of lectures and program time allocated to didactics, protected academic or study time for residents, and allocation of program time for CORE examinations are highly variable across programs. This could inspire future studies to be done to determine the differences in success of the resident on CORE examinations and in digesting material.

Postgraduate Career Plans and Fellowship Matches—Residents of programs that have a home MSDO fellowship are more likely to successfully match into a MSDO fellowship.⁵ Based on this survey, approximately 28% of graduating residents applied to a fellowship position, with 15%, 5%, and 3% matching into desired MSDO, dermatopathology, and pediatric dermatology fellowships, respectively. Additional studies are needed to determine advantages and disadvantages that lead to residents reaching their career goals.

Limitations—Limitations of this study include a small sample size that may not adequately represent all ACGME-accredited dermatology residency programs and selection bias toward respondents who are more likely to participate in survey-based research.

Conclusion

The APD plans to continue to administer this survey on an annual basis, with updates to the content and questions based on input from PDs. This survey will continue to provide valuable information to drive collaboration among residency programs and optimize the learning experience for residents. Our hope is that the response rate will increase in coming years, allowing us to draw more generalizable conclusions. Nonetheless, the survey data allow individual dermatology residency programs to compare their specific characteristics to other programs.

Educational organizations across several specialties, including internal medicine and obstetrics and gynecology, have formal surveys¹; however, the field of dermatology has been without one. This study aimed to establish a formal survey for dermatology program directors (PDs) and clinician-educators. Because the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Dermatology surveys do not capture all metrics relevant to dermatology residency educators, an annual survey for our specialty may be helpful to compare dermatology-specific data among programs. Responses could provide context and perspective to faculty and residents who respond to the ACGME annual survey, as our Association of Professors of Dermatology (APD) survey asks more in-depth questions, such as how often didactics occur and who leads them. Resident commute time and faculty demographics and training also are covered. Current ad hoc surveys disseminated through listserves of various medical associations contain overlapping questions and reflect relatively low response rates; dermatology PDs may benefit from a survey with a high response rate to which they can contribute future questions and topics that reflect recent trends and current needs in graduate medical education. As future surveys are administered, the results can be captured in a centralized database accessible by dermatology PDs.

Methods

A survey of PDs from 141 ACGME-accredited dermatology residency programs was conducted by the Residency Program Director Steering Committee of the APD from November 2022 to January 2023 using a prevalidated questionnaire. Personalized survey links were created and sent individually to each PD’s email listed in the ACGME accreditation data system. All survey responses were captured anonymously, with a number assigned to keep de-identified responses separate and organized. The survey consisted of 137 survey questions addressing topics that included program characteristics, PD demographics, the impact of the COVID-19 pandemic on clinical rotation and educational conferences, available resident resources, quality improvement, clinical and didactic instruction, research content, diversity and inclusion, wellness, professionalism, evaluation systems, and graduate outcomes.

Data were collected using Qualtrics survey tools. After removing duplicate and incomplete surveys, data were analyzed using Qualtrics reports and Microsoft Excel for data plotting, averages, and range calculations.

Results

One hundred forty-one personalized survey links were created and sent individually to each program’s filed email obtained from the APD listserv. Fifty-three responses were recorded after removing duplicate or incomplete surveys (38% [53/141] response rate). As of May 2023, there were 144 ACGME-accredited dermatology residency programs due to 3 newly accredited programs in 2022-2023 academic year, which were not included in our survey population.

Program Characteristics—Forty-four respondents (83%) were from a university-based program. Fifty respondents (94%) were from programs that were ACGME accredited prior to 2020, while 3 programs (6%) were American Osteopathic Association accredited prior to singular accreditation. Seventy-one percent (38/53) of respondents had 1 or more associate PDs.

PD Demographics—Eighty-seven percent (45/52) of PDs who responded to the survey graduated from a US allopathic medical school (MD), 10% (5/52) graduated from a US osteopathic medical school (DO), and 4% (2/52) graduated from an international medical school. Seventy-four percent (35/47) of respondents were White, 17% (8/47) were Asian, and 2% (1/47) were Black or African American; this data was not provided for 4 respondents. Forty-eight percent (23/48) of PDs identified as cisgender man, 48% (23/48) identified as cisgender woman, and 4% (2/48) preferred not to answer. Eighty-one percent (38/47) of PDs identified as heterosexual or straight, 15% (7/47) identified as gay or lesbian, and 4% (2/47) preferred not to answer.

Impact of COVID-19 Pandemic on Residency Training—Due to the COVID-19 pandemic, 88% (45/51) of respondents incorporated telemedicine into the resident clinical rotation schedule. Moving forward, 75% (38/51) of respondents indicated that their programs plan to continue to incorporate telemedicine into the rotation schedule. Based on 50 responses, the average of educational conferences that became virtual at the start of the COVID-19 pandemic was 87%; based on 46 responses, the percentage of educational conferences that will remain virtual moving forward is 46%, while 90% (46/51) of respondents indicated that their programs plan to use virtual conferences in some capacity moving forward. Seventy-three percent (37/51) of respondents indicated that they plan to use virtual interviews as part of residency recruitment moving forward.

Available Resources—Twenty-four percent (11/46) of respondents indicated that residents in their program do not get protected time or time off for CORE examinations. Seventy-five percent (33/44) of PDs said their program provides funding for residents to participate in board review courses. The chief residents at 63% (31/49) of programs receive additional compensation, and 69% (34/49) provide additional administrative time to chief residents. Seventy-one percent (24/34) of PDs reported their programs have scribes for attendings, and 12% (4/34) have scribes for residents. Support staff help residents with callbacks and in-basket messages according to 76% (35/46) of respondents. The majority (98% [45/46]) of PDs indicated that residents follow-up on results and messages from patients seen in resident clinics, and 43% (20/46) of programs have residents follow-up with patients seen in faculty clinics. Only 15% (7/46) of PDs responded they have schedules with residents dedicated to handle these tasks. According to respondents, 33% (17/52) have residents who are required to travel more than 25 miles to distant clinical sites. Of them, 35% (6/17) provide accommodations.

Quality Improvement—Seventy-one percent (35/49) of respondents indicated their department has a quality improvement/patient safety team or committee, and 94% (33/35) of these teams include residents. A lecture series on quality improvement and patient safety is offered at 67% (33/49) of the respondents’ programs, while morbidity and mortality conferences are offered in 73% (36/49).

Clinical Instruction—Our survey asked PDs how many months each residency year spends on a certain rotational service. Based on 46 respondents, the average number of months dedicated to medical dermatology is 7, 5, and 6 months for postgraduate year (PGY) 2, PGY3, and PGY4, respectively. The average number of months spent in other subspecialties is provided in the Table. On average, PGY2 residents spend 8 half-days per week seeing patients in clinic, while PGY3 and PGY4 residents see patients for 7 half-days. The median and mean number of patients staffed by a single attending per hour in teaching clinics are 6 and 5.88, respectively. Respondents indicated that residents participate in the following specialty clinics: pediatric dermatology (96% [44/46]), laser/cosmetic (87% [40/44]), high-risk skin cancer (ie, immunosuppressed/transplant patient)(65% [30/44]), pigmented lesion/melanoma (52% [24/44]), connective tissue disease (52% [24/44]), teledermatology (50% [23/44]), free clinic for homeless and/or indigent populations (48% [22/44]), contact dermatitis (43% [20/44]), skin of color (43% [20/44]), oncodermatology (41% [19/44]), and bullous disease (33% [15/44]).

Additionally, in 87% (40/46) of programs, residents participate in a dedicated inpatient consultation service. Most respondents (98% [45/46]) responded that they utilize in-person consultations with a teledermatology supplement. Fifteen percent (7/46) utilize virtual teledermatology (live video-based consultations), and 57% (26/46) utilize asynchronous teledermatology (picture-based consultations). All respondents (n=46) indicated that 0% to 25% of patient encounters involving residents are teledermatology visits. Thirty-three percent (6/18) of programs have a global health special training track, 56% (10/18) have a Specialty Training and Advanced Research/Physician-Scientist Research Training track, 28% (5/18) have a diversity training track, and 50% (9/18) have a clinician educator training track.

Didactic Instruction—Five programs have a full day per week dedicated to didactics, while 36 programs have at least one half-day per week for didactics. On average, didactics in 57% (26/46) of programs are led by faculty alone, while 43% (20/46) are led at least in part by residents or fellows.

Research Content—Fifty percent (23/46) of programs have a specific research requirement for residents beyond general ACGME requirements, and 35% (16/46) require residents to participate in a longitudinal research project over the course of residency. There is a dedicated research coordinator for resident support at 63% (29/46) of programs. Dedicated biostatistics research support is available for resident projects at 42% (19/45) of programs. Additionally, at 42% (19/45) of programs, there is a dedicated faculty member for oversight of resident research.

Diversity, Equity, and Inclusion—Seventy-three percent (29/40) of programs have special diversity, equity, and inclusion programs or meetings specific to residency, 60% (24/40) have residency initiatives, and 55% (22/40) have a residency diversity committee. Eighty-six percent (42/49) of respondents strongly agreed that their current residents represent diverse ethnic and racial backgrounds (ie, >15% are not White). eTable 1 shows PD responses to this statement, which were stratified based on self-identified race. eTable 2 shows PD responses to the statement, “Our current residents represent an inclusion of gender/sexual orientation,” which were stratified based on self-identified gender identity/sexual orientation. Lastly, eTable 3 highlights the percentage of residents with an MD and DO degree, stratified based on PD degree.

Wellness—Forty-eight percent (20/42) of respondents indicated they are under stress and do not always have as much energy as before becoming a PD but do not feel burned out. Thirty-one percent (13/42) indicated they have 1 or more symptoms of burnout, such as emotional exhaustion. Eighty-six percent (36/42) are satisfied with their jobs overall (43% agree and 43% strongly agree [18/42 each]).

Evaluation System—Seventy-five percent (33/44) of programs deliver evaluations of residents by faculty online, 86% (38/44) of programs have PDs discuss evaluations in-person, and 20% (9/44) of programs have faculty evaluators discuss evaluations in-person. Seventy-seven percent (34/44) of programs have formal faculty-resident mentor-mentee programs. Clinical competency committee chair positions are filled by PDs, assistant PDs, or core faculty members 47%, 38%, and 16% of the time, respectively.

Graduation Outcomes of PGY4 Residents—About 28% (55/199) of graduating residents applied to a fellowship position, with the majority (15% [29/55]) matching into Mohs micrographic surgery and dermatologic oncology (MSDO) fellowships. Approximately 5% (9/199) and 4% (7/199) of graduates matched into dermatopathology and pediatric dermatology, respectively. The remaining 5% (10/199) of graduating residents applied to a fellowship but did not match. The majority (45% [91/199]) of residency graduates entered private practice after graduation. Approximately 21% (42/199) of graduating residents chose an academic practice with 17% (33/199), 2% (4/199), and 2% (3/199) of those positions being full-time, part-time, and adjunct, respectively.

Comment

The first annual APD survey is a novel data source and provides opportunities for areas of discussion and investigation. Evaluating the similarities and differences among dermatology residency programs across the United States can strengthen individual programs through collaboration and provide areas of cohesion among programs.

Diversity of PDs—An important area of discussion is diversity and PD demographics. Although DO students make up 1 in 4 US graduating medical students, they are not interviewed or ranked as often as MD students.² Diversity in PD race and ethnicity may be worthy of investigation in future studies, as match rates and recruitment of diverse medical school applicants may be impacted by these demographics.

Continued Use of Telemedicine in Training—Since 2020, the benefits of virtual residency recruitment have been debated among PDs across all medical specialties. Points in favor of virtual interviews include cost savings for programs and especially for applicants, as well as time efficiency, reduced burden of travel, and reduced carbon footprint. A problem posed by virtual interviews is that candidates are unable to fully learn institutional cultures and social environments of the programs.³ Likewise, telehealth was an important means of clinical teaching for residents during the height of the COVID-19 pandemic, with benefits that included cost-effectiveness and reduction of disparities in access to dermatologic care.⁴ Seventy-five percent (38/51) of PDs indicated that their program plans to include telemedicine in resident clinical rotation moving forward.

Resources Available—Our survey showed that resources available for residents, delivery of lectures and program time allocated to didactics, protected academic or study time for residents, and allocation of program time for CORE examinations are highly variable across programs. This could inspire future studies to be done to determine the differences in success of the resident on CORE examinations and in digesting material.

Postgraduate Career Plans and Fellowship Matches—Residents of programs that have a home MSDO fellowship are more likely to successfully match into a MSDO fellowship.⁵ Based on this survey, approximately 28% of graduating residents applied to a fellowship position, with 15%, 5%, and 3% matching into desired MSDO, dermatopathology, and pediatric dermatology fellowships, respectively. Additional studies are needed to determine advantages and disadvantages that lead to residents reaching their career goals.

Limitations—Limitations of this study include a small sample size that may not adequately represent all ACGME-accredited dermatology residency programs and selection bias toward respondents who are more likely to participate in survey-based research.

Conclusion

The APD plans to continue to administer this survey on an annual basis, with updates to the content and questions based on input from PDs. This survey will continue to provide valuable information to drive collaboration among residency programs and optimize the learning experience for residents. Our hope is that the response rate will increase in coming years, allowing us to draw more generalizable conclusions. Nonetheless, the survey data allow individual dermatology residency programs to compare their specific characteristics to other programs.

Delusional infestation is the fixed false belief of skin infestation with a pathogen. Patients will often bring “proof” of their infestation to their visit to a physician. The presentation of a specimen was previously referred to by several names that reflected the receptacle that the patient utilized to bring the specimen (eg, a baggie or matchbox), but now the more encompassing term specimen sign is employed.¹ Establishing rapport with the patient is critically important in the treatment of delusional infestation. Examining the specimen samples brought by the patient is a simple manner of communicating to a patient that the clinician is empathetic to and respectful of his/her concerns.^2,3 The specimens often consist of dirt, dust, debris, fibers, and skin flakes and fragments, but they also have been reported to contain flies and insect parts.^4,5 In our case, the patient captured a minute brown scavenger beetle with adhesive tape.

Case Report

A woman in her mid-30s with a history of generalized anxiety disorder presented to the dermatology clinic with a concern of bugs infesting her skin. The symptoms occurred just after she moved into a new home with her family approximately 4 months prior to presentation. She felt the home was not cleaned properly, but they could not afford to move. She reported a crawling sensation that she identified as bugs biting her all over her body. Prior to presentation in the dermatology clinic, she and her family were treated by primary care for scabies 3 times with permethrin cream, and she was prescribed 1 course of oral ivermectin. She reported seeing bugs all over her house, which led her to clean her home and clothing many times. She was more concerned now because she thought her 2 children also were starting to be affected.

Physical examination revealed pressured speech, and the patient became tearful several times. The skin demonstrated several excoriations in various stages of healing on the breasts, legs, and upper back, as well as small scars in the same distribution. She brought several specimens stuck to clear tape to the visit. Examination of the specimens revealed fabric fibers; various debris; and a small, brown, 6-legged beetle with punctate indentations in rows along the wing covers (Figure). The head was narrower than the thorax, which was narrower than the abdomen.

We diagnosed the patient with a delusional infestation and discussed the beetle that we saw when examining the specimen the patient brought to the clinic. We provided reassurance that the minute brown scavenger beetle is not pathogenic and was present incidentally. Thus far, the patient has been resistant to initiating specific therapy for the delusional infestation, such as risperidone, olanzapine, or pimozide. We continue regular follow-up appointments with the patient to continue building the therapeutic relationship and revisiting the subject of treatment.

Comment

Minute brown scavenger beetles are arthropod members of the family Latridiidae. They also are commonly referred to as plaster or mold beetles. They are small (0.8–3.0 mm) and can be found in moist environments such as dead and rotting foliage, bird’s nests, debris, moist wallpaper/plaster, and stored products. They feed exclusively on fungus, such as mold and mildew, and pose no threat to humans.⁶ It is important for clinicians to recognize the appearance of the minute brown scavenger beetle so as not to mistake it for a pathogenic arthropod in patients presenting with delusional parasitosis.

Delusional infestation is the fixed false belief of skin infestation with a pathogen. Patients will often bring “proof” of their infestation to their visit to a physician. The presentation of a specimen was previously referred to by several names that reflected the receptacle that the patient utilized to bring the specimen (eg, a baggie or matchbox), but now the more encompassing term specimen sign is employed.¹ Establishing rapport with the patient is critically important in the treatment of delusional infestation. Examining the specimen samples brought by the patient is a simple manner of communicating to a patient that the clinician is empathetic to and respectful of his/her concerns.^2,3 The specimens often consist of dirt, dust, debris, fibers, and skin flakes and fragments, but they also have been reported to contain flies and insect parts.^4,5 In our case, the patient captured a minute brown scavenger beetle with adhesive tape.

Case Report

A woman in her mid-30s with a history of generalized anxiety disorder presented to the dermatology clinic with a concern of bugs infesting her skin. The symptoms occurred just after she moved into a new home with her family approximately 4 months prior to presentation. She felt the home was not cleaned properly, but they could not afford to move. She reported a crawling sensation that she identified as bugs biting her all over her body. Prior to presentation in the dermatology clinic, she and her family were treated by primary care for scabies 3 times with permethrin cream, and she was prescribed 1 course of oral ivermectin. She reported seeing bugs all over her house, which led her to clean her home and clothing many times. She was more concerned now because she thought her 2 children also were starting to be affected.

Physical examination revealed pressured speech, and the patient became tearful several times. The skin demonstrated several excoriations in various stages of healing on the breasts, legs, and upper back, as well as small scars in the same distribution. She brought several specimens stuck to clear tape to the visit. Examination of the specimens revealed fabric fibers; various debris; and a small, brown, 6-legged beetle with punctate indentations in rows along the wing covers (Figure). The head was narrower than the thorax, which was narrower than the abdomen.

We diagnosed the patient with a delusional infestation and discussed the beetle that we saw when examining the specimen the patient brought to the clinic. We provided reassurance that the minute brown scavenger beetle is not pathogenic and was present incidentally. Thus far, the patient has been resistant to initiating specific therapy for the delusional infestation, such as risperidone, olanzapine, or pimozide. We continue regular follow-up appointments with the patient to continue building the therapeutic relationship and revisiting the subject of treatment.

Comment

Minute brown scavenger beetles are arthropod members of the family Latridiidae. They also are commonly referred to as plaster or mold beetles. They are small (0.8–3.0 mm) and can be found in moist environments such as dead and rotting foliage, bird’s nests, debris, moist wallpaper/plaster, and stored products. They feed exclusively on fungus, such as mold and mildew, and pose no threat to humans.⁶ It is important for clinicians to recognize the appearance of the minute brown scavenger beetle so as not to mistake it for a pathogenic arthropod in patients presenting with delusional parasitosis.

Delusional infestation is the fixed false belief of skin infestation with a pathogen. Patients will often bring “proof” of their infestation to their visit to a physician. The presentation of a specimen was previously referred to by several names that reflected the receptacle that the patient utilized to bring the specimen (eg, a baggie or matchbox), but now the more encompassing term specimen sign is employed.¹ Establishing rapport with the patient is critically important in the treatment of delusional infestation. Examining the specimen samples brought by the patient is a simple manner of communicating to a patient that the clinician is empathetic to and respectful of his/her concerns.^2,3 The specimens often consist of dirt, dust, debris, fibers, and skin flakes and fragments, but they also have been reported to contain flies and insect parts.^4,5 In our case, the patient captured a minute brown scavenger beetle with adhesive tape.

Case Report

A woman in her mid-30s with a history of generalized anxiety disorder presented to the dermatology clinic with a concern of bugs infesting her skin. The symptoms occurred just after she moved into a new home with her family approximately 4 months prior to presentation. She felt the home was not cleaned properly, but they could not afford to move. She reported a crawling sensation that she identified as bugs biting her all over her body. Prior to presentation in the dermatology clinic, she and her family were treated by primary care for scabies 3 times with permethrin cream, and she was prescribed 1 course of oral ivermectin. She reported seeing bugs all over her house, which led her to clean her home and clothing many times. She was more concerned now because she thought her 2 children also were starting to be affected.

Physical examination revealed pressured speech, and the patient became tearful several times. The skin demonstrated several excoriations in various stages of healing on the breasts, legs, and upper back, as well as small scars in the same distribution. She brought several specimens stuck to clear tape to the visit. Examination of the specimens revealed fabric fibers; various debris; and a small, brown, 6-legged beetle with punctate indentations in rows along the wing covers (Figure). The head was narrower than the thorax, which was narrower than the abdomen.

We diagnosed the patient with a delusional infestation and discussed the beetle that we saw when examining the specimen the patient brought to the clinic. We provided reassurance that the minute brown scavenger beetle is not pathogenic and was present incidentally. Thus far, the patient has been resistant to initiating specific therapy for the delusional infestation, such as risperidone, olanzapine, or pimozide. We continue regular follow-up appointments with the patient to continue building the therapeutic relationship and revisiting the subject of treatment.

Comment

Minute brown scavenger beetles are arthropod members of the family Latridiidae. They also are commonly referred to as plaster or mold beetles. They are small (0.8–3.0 mm) and can be found in moist environments such as dead and rotting foliage, bird’s nests, debris, moist wallpaper/plaster, and stored products. They feed exclusively on fungus, such as mold and mildew, and pose no threat to humans.⁶ It is important for clinicians to recognize the appearance of the minute brown scavenger beetle so as not to mistake it for a pathogenic arthropod in patients presenting with delusional parasitosis.