For Residents

To the Editor:

Micrographic surgery and dermatologic oncology (MSDO) is a highly competitive subspecialty fellowship in dermatology. Prospective applicants often depend on the Internet to obtain pertinent information about fellowship programs to navigate the application process. An up-to-date and comprehensive fellowship website has the potential to be advantageous for both applicants and programs—applicants can more readily identify programs that align with their goals and values, and programs can effectively attract compatible applicants. These advantages are increasingly relevant with the virtual application process that has become essential considering the COVID-19 pandemic. At the height of the COVID-19 pandemic in 2020, we sought to evaluate the comprehensiveness of the content of Accreditation Council for Graduate Medical Education (ACGME) MSDO fellowship program websites to identify possible areas for improvement.

We obtained a list of all ACGME MSDO fellowships from the ACGME website (https://www.acgme.org/) and verified it against the list of MSDO programs in FREIDA, the American Medical Association residency and fellowship database (https://freida.ama-assn.org/). All programs without a website were excluded from further analysis. All data collection from currently accessible fellowship websites and evaluation occurred in April 2020.

The remaining MSDO fellowship program websites were evaluated using 25 criteria distributed among 5 domains: education/research, clinical training, program information, application process, and incentives. These criteria were determined based on earlier studies that similarly evaluated the website content of fellowship programs with inclusion of information that was considered valuable in the appraisal of fellowship programs.^1,2 Criteria were further refined by direct consideration of relevance and importance to MSDO fellowship applicants (eg, inclusion of case volume, exclusion of call schedule).

Each criterion was independently assessed by 2 investigators (J.Y.C. and S.J.E.S.). A third investigator (J.R.P.) then independently evaluated those 2 assessments for agreement. Where disagreement was discovered, the third evaluator (J.R.P.) provided a final appraisal. Cohen’s kappa (κ) was conducted to evaluate for concordance between the 2 primary website evaluators. We found there to be substantial agreement between the reviewers within the education/research (κ [SD]=0.772 [0.077]), clinical training (κ [SD]=0.740 [0.051]), application process (κ [SD]=0.726 [0.103]), and incentives domains (κ [SD]=0.730 [0.110]). There was moderate agreement (κ [SD]=0.603 [0.128]) between the reviewers within the program information domain.

We identified 77 active MSDO fellowship programs. Sixty of those 77 programs (77.9%) had a dedicated fellowship website that was readily accessible. Most programs that had a dedicated fellowship website had a core or affiliated residency program (49/60 [81.7%]).

Websites that we evaluated fulfilled a mean (SD) of 9.37 (4.17) of the 25 identified criteria. Only 13 of 60 (21.7%) websites fulfilled more than 50% of evaluated criteria.

There was no statistical difference in the number of criteria fulfilled based on whether the fellowship program had a core or affiliated residency program.

Upon reviewing website accessibility directly from FREIDA, only 5 of 60 programs (8.3%) provided applicants with a link directly to their fellowship page (Table). Most programs (41 [68.3%]) provided a link to the dermatology department website, not to the specific fellowship program page, thus requiring a multistep process to find the fellowship-specific page. The remaining programs had an inaccessible (4 [6.7%]) or absent (10 [16.7%]) link on FREIDA, though a fellowship website could be identified by an Internet search of the program name.

CT112002001_e_Table.jpg

The domain most fulfilled was program information with an average of 51.1% of programs satisfying the criteria, whereas the incentives domain was least fulfilled with an average of only 20.8% of programs satisfying the criteria. Across the various criteria, websites more often included a description of the program (58 [96.6%]), mentioned accreditation (53 [88.3%]), and provided case descriptions (48 [80.0%]). They less often reported information regarding a fellow’s call responsibility (3 [5%]); evaluation criteria (5 [8.3%]); and rotation schedule or options (6 [10.0%]).

The highest number of criteria fulfilled by a single program was 19 (76%). The lowest number of criteria met was 2 (8%). These findings suggest a large variation in comprehensiveness across fellowship websites.

Our research suggests that many current MSDO fellowship programs have room to maximize the information provided to applicants through their websites, which is particularly relevant following the COVID-19 pandemic, as the value of providing comprehensive and transparent information through an online platform is greater than ever. Given the ongoing desire to limit travel, virtual methods for navigating the application process have been readily used, including online videoconferencing for interviews and virtual program visits. This scenario has placed applicants in a challenging situation—their ability to directly evaluate their compatibility with a given program has been limited.³

Earlier studies that analyzed rheumatology fellowship recruitment during the COVID-19 pandemic found that programs may have more difficulty highlighting the strengths of their institution (eg, clinical facilities, professional opportunities, educational environment).⁴ An updated and comprehensive fellowship website was recommended⁴ as a key part in facing these new challenges. On the other hand, given the large number of applicants each year for fellowship positions in any given program, we acknowledge the potential benefit programs may obtain from limiting electronic information that is readily accessible to all applicants, as doing so may encourage applicants to communicate directly with a program and allow programs to identify candidates who are more interested.

In light of the movement to a more virtual-friendly and technology-driven fellowship application process, we identified 25 content areas that fellowships may want to include on their websites so that potential applicants can be well informed about the program before submitting an application and scheduling an interview. Efforts to improve accessibility and maximize the content of these websites may help programs attract compatible candidates, improve transparency, and guide applicants throughout the application process.

To the Editor:

Micrographic surgery and dermatologic oncology (MSDO) is a highly competitive subspecialty fellowship in dermatology. Prospective applicants often depend on the Internet to obtain pertinent information about fellowship programs to navigate the application process. An up-to-date and comprehensive fellowship website has the potential to be advantageous for both applicants and programs—applicants can more readily identify programs that align with their goals and values, and programs can effectively attract compatible applicants. These advantages are increasingly relevant with the virtual application process that has become essential considering the COVID-19 pandemic. At the height of the COVID-19 pandemic in 2020, we sought to evaluate the comprehensiveness of the content of Accreditation Council for Graduate Medical Education (ACGME) MSDO fellowship program websites to identify possible areas for improvement.

We obtained a list of all ACGME MSDO fellowships from the ACGME website (https://www.acgme.org/) and verified it against the list of MSDO programs in FREIDA, the American Medical Association residency and fellowship database (https://freida.ama-assn.org/). All programs without a website were excluded from further analysis. All data collection from currently accessible fellowship websites and evaluation occurred in April 2020.

The remaining MSDO fellowship program websites were evaluated using 25 criteria distributed among 5 domains: education/research, clinical training, program information, application process, and incentives. These criteria were determined based on earlier studies that similarly evaluated the website content of fellowship programs with inclusion of information that was considered valuable in the appraisal of fellowship programs.^1,2 Criteria were further refined by direct consideration of relevance and importance to MSDO fellowship applicants (eg, inclusion of case volume, exclusion of call schedule).

Each criterion was independently assessed by 2 investigators (J.Y.C. and S.J.E.S.). A third investigator (J.R.P.) then independently evaluated those 2 assessments for agreement. Where disagreement was discovered, the third evaluator (J.R.P.) provided a final appraisal. Cohen’s kappa (κ) was conducted to evaluate for concordance between the 2 primary website evaluators. We found there to be substantial agreement between the reviewers within the education/research (κ [SD]=0.772 [0.077]), clinical training (κ [SD]=0.740 [0.051]), application process (κ [SD]=0.726 [0.103]), and incentives domains (κ [SD]=0.730 [0.110]). There was moderate agreement (κ [SD]=0.603 [0.128]) between the reviewers within the program information domain.

We identified 77 active MSDO fellowship programs. Sixty of those 77 programs (77.9%) had a dedicated fellowship website that was readily accessible. Most programs that had a dedicated fellowship website had a core or affiliated residency program (49/60 [81.7%]).

Websites that we evaluated fulfilled a mean (SD) of 9.37 (4.17) of the 25 identified criteria. Only 13 of 60 (21.7%) websites fulfilled more than 50% of evaluated criteria.

There was no statistical difference in the number of criteria fulfilled based on whether the fellowship program had a core or affiliated residency program.

Upon reviewing website accessibility directly from FREIDA, only 5 of 60 programs (8.3%) provided applicants with a link directly to their fellowship page (Table). Most programs (41 [68.3%]) provided a link to the dermatology department website, not to the specific fellowship program page, thus requiring a multistep process to find the fellowship-specific page. The remaining programs had an inaccessible (4 [6.7%]) or absent (10 [16.7%]) link on FREIDA, though a fellowship website could be identified by an Internet search of the program name.

CT112002001_e_Table.jpg

The domain most fulfilled was program information with an average of 51.1% of programs satisfying the criteria, whereas the incentives domain was least fulfilled with an average of only 20.8% of programs satisfying the criteria. Across the various criteria, websites more often included a description of the program (58 [96.6%]), mentioned accreditation (53 [88.3%]), and provided case descriptions (48 [80.0%]). They less often reported information regarding a fellow’s call responsibility (3 [5%]); evaluation criteria (5 [8.3%]); and rotation schedule or options (6 [10.0%]).

The highest number of criteria fulfilled by a single program was 19 (76%). The lowest number of criteria met was 2 (8%). These findings suggest a large variation in comprehensiveness across fellowship websites.

Our research suggests that many current MSDO fellowship programs have room to maximize the information provided to applicants through their websites, which is particularly relevant following the COVID-19 pandemic, as the value of providing comprehensive and transparent information through an online platform is greater than ever. Given the ongoing desire to limit travel, virtual methods for navigating the application process have been readily used, including online videoconferencing for interviews and virtual program visits. This scenario has placed applicants in a challenging situation—their ability to directly evaluate their compatibility with a given program has been limited.³

Earlier studies that analyzed rheumatology fellowship recruitment during the COVID-19 pandemic found that programs may have more difficulty highlighting the strengths of their institution (eg, clinical facilities, professional opportunities, educational environment).⁴ An updated and comprehensive fellowship website was recommended⁴ as a key part in facing these new challenges. On the other hand, given the large number of applicants each year for fellowship positions in any given program, we acknowledge the potential benefit programs may obtain from limiting electronic information that is readily accessible to all applicants, as doing so may encourage applicants to communicate directly with a program and allow programs to identify candidates who are more interested.

In light of the movement to a more virtual-friendly and technology-driven fellowship application process, we identified 25 content areas that fellowships may want to include on their websites so that potential applicants can be well informed about the program before submitting an application and scheduling an interview. Efforts to improve accessibility and maximize the content of these websites may help programs attract compatible candidates, improve transparency, and guide applicants throughout the application process.

To the Editor:

Micrographic surgery and dermatologic oncology (MSDO) is a highly competitive subspecialty fellowship in dermatology. Prospective applicants often depend on the Internet to obtain pertinent information about fellowship programs to navigate the application process. An up-to-date and comprehensive fellowship website has the potential to be advantageous for both applicants and programs—applicants can more readily identify programs that align with their goals and values, and programs can effectively attract compatible applicants. These advantages are increasingly relevant with the virtual application process that has become essential considering the COVID-19 pandemic. At the height of the COVID-19 pandemic in 2020, we sought to evaluate the comprehensiveness of the content of Accreditation Council for Graduate Medical Education (ACGME) MSDO fellowship program websites to identify possible areas for improvement.

We obtained a list of all ACGME MSDO fellowships from the ACGME website (https://www.acgme.org/) and verified it against the list of MSDO programs in FREIDA, the American Medical Association residency and fellowship database (https://freida.ama-assn.org/). All programs without a website were excluded from further analysis. All data collection from currently accessible fellowship websites and evaluation occurred in April 2020.

The remaining MSDO fellowship program websites were evaluated using 25 criteria distributed among 5 domains: education/research, clinical training, program information, application process, and incentives. These criteria were determined based on earlier studies that similarly evaluated the website content of fellowship programs with inclusion of information that was considered valuable in the appraisal of fellowship programs.^1,2 Criteria were further refined by direct consideration of relevance and importance to MSDO fellowship applicants (eg, inclusion of case volume, exclusion of call schedule).

Each criterion was independently assessed by 2 investigators (J.Y.C. and S.J.E.S.). A third investigator (J.R.P.) then independently evaluated those 2 assessments for agreement. Where disagreement was discovered, the third evaluator (J.R.P.) provided a final appraisal. Cohen’s kappa (κ) was conducted to evaluate for concordance between the 2 primary website evaluators. We found there to be substantial agreement between the reviewers within the education/research (κ [SD]=0.772 [0.077]), clinical training (κ [SD]=0.740 [0.051]), application process (κ [SD]=0.726 [0.103]), and incentives domains (κ [SD]=0.730 [0.110]). There was moderate agreement (κ [SD]=0.603 [0.128]) between the reviewers within the program information domain.

We identified 77 active MSDO fellowship programs. Sixty of those 77 programs (77.9%) had a dedicated fellowship website that was readily accessible. Most programs that had a dedicated fellowship website had a core or affiliated residency program (49/60 [81.7%]).

Websites that we evaluated fulfilled a mean (SD) of 9.37 (4.17) of the 25 identified criteria. Only 13 of 60 (21.7%) websites fulfilled more than 50% of evaluated criteria.

There was no statistical difference in the number of criteria fulfilled based on whether the fellowship program had a core or affiliated residency program.

Upon reviewing website accessibility directly from FREIDA, only 5 of 60 programs (8.3%) provided applicants with a link directly to their fellowship page (Table). Most programs (41 [68.3%]) provided a link to the dermatology department website, not to the specific fellowship program page, thus requiring a multistep process to find the fellowship-specific page. The remaining programs had an inaccessible (4 [6.7%]) or absent (10 [16.7%]) link on FREIDA, though a fellowship website could be identified by an Internet search of the program name.

CT112002001_e_Table.jpg

The domain most fulfilled was program information with an average of 51.1% of programs satisfying the criteria, whereas the incentives domain was least fulfilled with an average of only 20.8% of programs satisfying the criteria. Across the various criteria, websites more often included a description of the program (58 [96.6%]), mentioned accreditation (53 [88.3%]), and provided case descriptions (48 [80.0%]). They less often reported information regarding a fellow’s call responsibility (3 [5%]); evaluation criteria (5 [8.3%]); and rotation schedule or options (6 [10.0%]).

The highest number of criteria fulfilled by a single program was 19 (76%). The lowest number of criteria met was 2 (8%). These findings suggest a large variation in comprehensiveness across fellowship websites.

Our research suggests that many current MSDO fellowship programs have room to maximize the information provided to applicants through their websites, which is particularly relevant following the COVID-19 pandemic, as the value of providing comprehensive and transparent information through an online platform is greater than ever. Given the ongoing desire to limit travel, virtual methods for navigating the application process have been readily used, including online videoconferencing for interviews and virtual program visits. This scenario has placed applicants in a challenging situation—their ability to directly evaluate their compatibility with a given program has been limited.³

Earlier studies that analyzed rheumatology fellowship recruitment during the COVID-19 pandemic found that programs may have more difficulty highlighting the strengths of their institution (eg, clinical facilities, professional opportunities, educational environment).⁴ An updated and comprehensive fellowship website was recommended⁴ as a key part in facing these new challenges. On the other hand, given the large number of applicants each year for fellowship positions in any given program, we acknowledge the potential benefit programs may obtain from limiting electronic information that is readily accessible to all applicants, as doing so may encourage applicants to communicate directly with a program and allow programs to identify candidates who are more interested.

In light of the movement to a more virtual-friendly and technology-driven fellowship application process, we identified 25 content areas that fellowships may want to include on their websites so that potential applicants can be well informed about the program before submitting an application and scheduling an interview. Efforts to improve accessibility and maximize the content of these websites may help programs attract compatible candidates, improve transparency, and guide applicants throughout the application process.

To the Editor:

With health care constituting one of the larger segments of the US economy, medical practice is increasingly subject to business considerations.¹ Patients, providers, and organizations are all required to make decisions that reflect choices beyond clinical needs alone. Given the impact of market forces, clinicians often are asked to navigate operational and business decisions. Accordingly, education about the policy and systems that shape care delivery can improve quality and help patients.²

The ability to understand the ecosystem of health care is of utmost importance for medical providers and can be achieved through resident education. Teaching fundamental business concepts enables residents to deliver care that is responsive to the constraints and opportunities encountered by patients and organizations, which ultimately will better prepare them to serve as advocates in alignment with their principal duties as physicians.

Despite the recognizable relationship between business and medicine, training has not yet been standardized to include topics in business education, and clinicians in dermatology are remarkably positioned to benefit because of the variety of practice settings and services they can provide. In dermatology, the diversity of services provided gives rise to complex coding and use of modifiers. Proper utilization of coding and billing is critical to create accurate documentation and receive appropriate reimbursement.³ Furthermore, clinicians in dermatology have to contend with the influence of insurance at many points of care, such as with coverage of pharmaceuticals. Formularies often have wide variability in coverage and are changing as new drugs come to market in the dermatologic space.⁴

The landscape of practice structure also has undergone change with increasing consolidation and mergers. The acquisition of practices by private equity firms has induced changes in practice infrastructure. The impact of changing organizational and managerial influences continues to be a topic of debate, with disparate opinions on how these developments shape standards of physician satisfaction and patient care.⁵

The convergence of these factors points to an important question that is gaining popularity: How will young dermatologists work within the context of all these parameters to best advocate and care for their patients? These questions are garnering more attention and were recently investigated through a survey of participants in a pilot program to evaluate the importance of business education in dermatology residency.

A survey of residency program directors was created by Patrinley and Dewan,⁶ which found that business education during residency was important and additional training should be implemented. Despite the perceived importance of business education, only half of the programs represented by survey respondents offered any structured educational opportunities, revealing a discrepancy between believed importance and practical implementation of business training, which suggests the need to develop a standardized, dermatology-specific curriculum that could be accessed by all residents in training.⁶

We performed a search of the medical literature to identify models of business education in residency programs. Only a few programs were identified, in which courses were predominantly instructed to trainees in primary care–based fields. According to course graduates, the programs were beneficial.^7,8 Programs that had descriptive information about curriculum structure and content were chosen for further investigation and included internal medicine programs at the University of California San Francisco (UCSF) and Columbia University Vagelos College of Physicians and Surgeons (New York, New York). UCSF implemented a Program in Residency Investigation Methods and Epidemiology (PRIME program) to deliver seven 90-minute sessions dedicated to introducing residents to medical economics. Sessions were constructed with the intent of being interactive seminars that took on a variety of forms, including reading-based discussions, case-based analysis, and simulation-based learning.⁷ Columbia University developed a pilot program of week-long didactic sessions that were delivered to third-year internal medicine residents. These seminars featured discussions on health policy and economics, health insurance, technology and cost assessment, legal medicine, public health, community-oriented primary care, and local health department initiatives.⁸ We drew on both courses to build a lecture series focused on the business of dermatology that was delivered to dermatology residents at UMass Chan Medical School (Worcester, Massachusetts). Topic selection also was informed by qualitative input collected via email from recent graduates of the UMass dermatology residency program, focusing on the following areas: the US medical economy and health care costs; billing, coding, and claims processing; quality, relative value units (RVUs), reimbursement, and the merit-based incentive payment system; coverage of pharmaceuticals and teledermatology; and management. Residents were not required to prepare for any of the sessions; they were provided with handouts and slideshow presentations for reference to review at their convenience if desired. Five seminars were virtually conducted by an MD/MBA candidate at the institution (E.H.). They were recorded over the course of an academic year at 1- to 2-month intervals. Each 45-minute session was conducted in a lecture-discussion format and included case examples to help illustrate key principles and stimulate conversation. For example, the lecture on reimbursement incorporated a fee schedule calculation for a shave biopsy, using RVU and geographic pricing cost index (GCPI) multipliers. This demonstrated the variation in Centers for Medicare & Medicaid Services reimbursement in relation to (1) constituents of the RVU calculation (ie, work, practice expense, and malpractice) and (2) practice in a particular location (ie, the GCPI). Following this example, a conversation ensued among participants regarding the factors that drive valuation, with particular interest in variation based on urban vs suburban locations across the United States. Participants also found it of interest to examine the percentage of the valuation dedicated to each constituent and how features such as lesion size informed the final assessment of the charge. Another stylistic choice in developing the model was to include prompts for further consideration prior to transitioning topics in the lectures. For example: when examining the burden of skin disease, the audience was prompted to consider: “What is driving cost escalations, and how will services of the clinical domain meet these evolving needs?” At another point in the introductory lecture, residents were asked: “How do different types of insurance plans impact the management of patients with dermatologic concerns?” These questions were intended to transition residents to the next topic of discussion and highlight take-home points of consideration for medical practice. The project was reviewed by the UMass institutional review board and met criteria for exemption.

Residents who participated in at least 1 lecture (N=10) were surveyed after attendance; there were 7 responses (70% response rate). Residents were asked to rate a series of statements on a scale of 1 (strongly disagree) to 5 (strongly agree) and to provide commentary via an online form. Respondents indicated that the course was enjoyable (average score, 4.00), provided an appropriate level of detail (average score, 4.00), would be beneficial to integrate into a dermatology residency curriculum (average score, 3.86), and informed how they would practice as a clinician (average score, 3.86)(Figure). The respondents agreed that the course met the main goals of this initiative: it helped them develop knowledge about the interface between business and dermatology (4.14) and exposed residents to topics they had not learned about previously (4.71).

Herringshaw.jpg

Although the course generally was well received, areas for improvement were identified from respondents’ comments, relating to audience engagement and refining the level of detail in the lectures. Recommendations included “less technical jargon and more focus on ‘big picture’ concepts, given audience’s low baseline knowledge”; “more case examples in each module”; and “more diagrams or interactive activities (polls, quizzes, break-out rooms) because the lectures were a bit dense.” This input was taken into consideration when revising the lectures for future use; they were reconstructed to have more case-based examples and prompts to encourage participation.

Resident commentary also demonstrated appreciation for education in this subject material. Statements such as “this is an important topic for future dermatologists” and “thank you so much for taking the time to implement this course” reflected the perceived value of this material during critical academic time. Another resident remarked: “This was great, thanks for putting it together.”

Given the positive experience of the residents and successful implementation of the series, this course was made available to all dermatology trainees on a network server with accompanying written documents. It is planned to be offered on a 3-year cycle in the future and will be updated to reflect inevitable changes in health care.

Although the relationship between business and medicine is increasingly important, teaching business principles has not become standardized or required in medical training. Despite the perception that this content is of value, implementation of programming has lagged behind that recognition, likely due to challenges in designing the curriculum and diffusing content into an already-saturated schedule. A model course that can be replicated in other residency programs would be valuable. We introduced a dermatology-specific lecture series to help prepare trainees for dermatology practice in a variety of clinical settings and train them with the language of business and operations that will equip them to respond to the needs of their patients, their practice, and the medical environment. Findings of this pilot study may not be generalizable to all dermatology residency programs because the sample size was small; the study was conducted at a single institution; and the content was delivered entirely online.

To the Editor:

With health care constituting one of the larger segments of the US economy, medical practice is increasingly subject to business considerations.¹ Patients, providers, and organizations are all required to make decisions that reflect choices beyond clinical needs alone. Given the impact of market forces, clinicians often are asked to navigate operational and business decisions. Accordingly, education about the policy and systems that shape care delivery can improve quality and help patients.²

The ability to understand the ecosystem of health care is of utmost importance for medical providers and can be achieved through resident education. Teaching fundamental business concepts enables residents to deliver care that is responsive to the constraints and opportunities encountered by patients and organizations, which ultimately will better prepare them to serve as advocates in alignment with their principal duties as physicians.

Despite the recognizable relationship between business and medicine, training has not yet been standardized to include topics in business education, and clinicians in dermatology are remarkably positioned to benefit because of the variety of practice settings and services they can provide. In dermatology, the diversity of services provided gives rise to complex coding and use of modifiers. Proper utilization of coding and billing is critical to create accurate documentation and receive appropriate reimbursement.³ Furthermore, clinicians in dermatology have to contend with the influence of insurance at many points of care, such as with coverage of pharmaceuticals. Formularies often have wide variability in coverage and are changing as new drugs come to market in the dermatologic space.⁴

The landscape of practice structure also has undergone change with increasing consolidation and mergers. The acquisition of practices by private equity firms has induced changes in practice infrastructure. The impact of changing organizational and managerial influences continues to be a topic of debate, with disparate opinions on how these developments shape standards of physician satisfaction and patient care.⁵

The convergence of these factors points to an important question that is gaining popularity: How will young dermatologists work within the context of all these parameters to best advocate and care for their patients? These questions are garnering more attention and were recently investigated through a survey of participants in a pilot program to evaluate the importance of business education in dermatology residency.

A survey of residency program directors was created by Patrinley and Dewan,⁶ which found that business education during residency was important and additional training should be implemented. Despite the perceived importance of business education, only half of the programs represented by survey respondents offered any structured educational opportunities, revealing a discrepancy between believed importance and practical implementation of business training, which suggests the need to develop a standardized, dermatology-specific curriculum that could be accessed by all residents in training.⁶

We performed a search of the medical literature to identify models of business education in residency programs. Only a few programs were identified, in which courses were predominantly instructed to trainees in primary care–based fields. According to course graduates, the programs were beneficial.^7,8 Programs that had descriptive information about curriculum structure and content were chosen for further investigation and included internal medicine programs at the University of California San Francisco (UCSF) and Columbia University Vagelos College of Physicians and Surgeons (New York, New York). UCSF implemented a Program in Residency Investigation Methods and Epidemiology (PRIME program) to deliver seven 90-minute sessions dedicated to introducing residents to medical economics. Sessions were constructed with the intent of being interactive seminars that took on a variety of forms, including reading-based discussions, case-based analysis, and simulation-based learning.⁷ Columbia University developed a pilot program of week-long didactic sessions that were delivered to third-year internal medicine residents. These seminars featured discussions on health policy and economics, health insurance, technology and cost assessment, legal medicine, public health, community-oriented primary care, and local health department initiatives.⁸ We drew on both courses to build a lecture series focused on the business of dermatology that was delivered to dermatology residents at UMass Chan Medical School (Worcester, Massachusetts). Topic selection also was informed by qualitative input collected via email from recent graduates of the UMass dermatology residency program, focusing on the following areas: the US medical economy and health care costs; billing, coding, and claims processing; quality, relative value units (RVUs), reimbursement, and the merit-based incentive payment system; coverage of pharmaceuticals and teledermatology; and management. Residents were not required to prepare for any of the sessions; they were provided with handouts and slideshow presentations for reference to review at their convenience if desired. Five seminars were virtually conducted by an MD/MBA candidate at the institution (E.H.). They were recorded over the course of an academic year at 1- to 2-month intervals. Each 45-minute session was conducted in a lecture-discussion format and included case examples to help illustrate key principles and stimulate conversation. For example, the lecture on reimbursement incorporated a fee schedule calculation for a shave biopsy, using RVU and geographic pricing cost index (GCPI) multipliers. This demonstrated the variation in Centers for Medicare & Medicaid Services reimbursement in relation to (1) constituents of the RVU calculation (ie, work, practice expense, and malpractice) and (2) practice in a particular location (ie, the GCPI). Following this example, a conversation ensued among participants regarding the factors that drive valuation, with particular interest in variation based on urban vs suburban locations across the United States. Participants also found it of interest to examine the percentage of the valuation dedicated to each constituent and how features such as lesion size informed the final assessment of the charge. Another stylistic choice in developing the model was to include prompts for further consideration prior to transitioning topics in the lectures. For example: when examining the burden of skin disease, the audience was prompted to consider: “What is driving cost escalations, and how will services of the clinical domain meet these evolving needs?” At another point in the introductory lecture, residents were asked: “How do different types of insurance plans impact the management of patients with dermatologic concerns?” These questions were intended to transition residents to the next topic of discussion and highlight take-home points of consideration for medical practice. The project was reviewed by the UMass institutional review board and met criteria for exemption.

Residents who participated in at least 1 lecture (N=10) were surveyed after attendance; there were 7 responses (70% response rate). Residents were asked to rate a series of statements on a scale of 1 (strongly disagree) to 5 (strongly agree) and to provide commentary via an online form. Respondents indicated that the course was enjoyable (average score, 4.00), provided an appropriate level of detail (average score, 4.00), would be beneficial to integrate into a dermatology residency curriculum (average score, 3.86), and informed how they would practice as a clinician (average score, 3.86)(Figure). The respondents agreed that the course met the main goals of this initiative: it helped them develop knowledge about the interface between business and dermatology (4.14) and exposed residents to topics they had not learned about previously (4.71).

Herringshaw.jpg

Although the course generally was well received, areas for improvement were identified from respondents’ comments, relating to audience engagement and refining the level of detail in the lectures. Recommendations included “less technical jargon and more focus on ‘big picture’ concepts, given audience’s low baseline knowledge”; “more case examples in each module”; and “more diagrams or interactive activities (polls, quizzes, break-out rooms) because the lectures were a bit dense.” This input was taken into consideration when revising the lectures for future use; they were reconstructed to have more case-based examples and prompts to encourage participation.

Resident commentary also demonstrated appreciation for education in this subject material. Statements such as “this is an important topic for future dermatologists” and “thank you so much for taking the time to implement this course” reflected the perceived value of this material during critical academic time. Another resident remarked: “This was great, thanks for putting it together.”

Given the positive experience of the residents and successful implementation of the series, this course was made available to all dermatology trainees on a network server with accompanying written documents. It is planned to be offered on a 3-year cycle in the future and will be updated to reflect inevitable changes in health care.

Although the relationship between business and medicine is increasingly important, teaching business principles has not become standardized or required in medical training. Despite the perception that this content is of value, implementation of programming has lagged behind that recognition, likely due to challenges in designing the curriculum and diffusing content into an already-saturated schedule. A model course that can be replicated in other residency programs would be valuable. We introduced a dermatology-specific lecture series to help prepare trainees for dermatology practice in a variety of clinical settings and train them with the language of business and operations that will equip them to respond to the needs of their patients, their practice, and the medical environment. Findings of this pilot study may not be generalizable to all dermatology residency programs because the sample size was small; the study was conducted at a single institution; and the content was delivered entirely online.

To the Editor:

With health care constituting one of the larger segments of the US economy, medical practice is increasingly subject to business considerations.¹ Patients, providers, and organizations are all required to make decisions that reflect choices beyond clinical needs alone. Given the impact of market forces, clinicians often are asked to navigate operational and business decisions. Accordingly, education about the policy and systems that shape care delivery can improve quality and help patients.²

The ability to understand the ecosystem of health care is of utmost importance for medical providers and can be achieved through resident education. Teaching fundamental business concepts enables residents to deliver care that is responsive to the constraints and opportunities encountered by patients and organizations, which ultimately will better prepare them to serve as advocates in alignment with their principal duties as physicians.

Despite the recognizable relationship between business and medicine, training has not yet been standardized to include topics in business education, and clinicians in dermatology are remarkably positioned to benefit because of the variety of practice settings and services they can provide. In dermatology, the diversity of services provided gives rise to complex coding and use of modifiers. Proper utilization of coding and billing is critical to create accurate documentation and receive appropriate reimbursement.³ Furthermore, clinicians in dermatology have to contend with the influence of insurance at many points of care, such as with coverage of pharmaceuticals. Formularies often have wide variability in coverage and are changing as new drugs come to market in the dermatologic space.⁴

The landscape of practice structure also has undergone change with increasing consolidation and mergers. The acquisition of practices by private equity firms has induced changes in practice infrastructure. The impact of changing organizational and managerial influences continues to be a topic of debate, with disparate opinions on how these developments shape standards of physician satisfaction and patient care.⁵

The convergence of these factors points to an important question that is gaining popularity: How will young dermatologists work within the context of all these parameters to best advocate and care for their patients? These questions are garnering more attention and were recently investigated through a survey of participants in a pilot program to evaluate the importance of business education in dermatology residency.

A survey of residency program directors was created by Patrinley and Dewan,⁶ which found that business education during residency was important and additional training should be implemented. Despite the perceived importance of business education, only half of the programs represented by survey respondents offered any structured educational opportunities, revealing a discrepancy between believed importance and practical implementation of business training, which suggests the need to develop a standardized, dermatology-specific curriculum that could be accessed by all residents in training.⁶

We performed a search of the medical literature to identify models of business education in residency programs. Only a few programs were identified, in which courses were predominantly instructed to trainees in primary care–based fields. According to course graduates, the programs were beneficial.^7,8 Programs that had descriptive information about curriculum structure and content were chosen for further investigation and included internal medicine programs at the University of California San Francisco (UCSF) and Columbia University Vagelos College of Physicians and Surgeons (New York, New York). UCSF implemented a Program in Residency Investigation Methods and Epidemiology (PRIME program) to deliver seven 90-minute sessions dedicated to introducing residents to medical economics. Sessions were constructed with the intent of being interactive seminars that took on a variety of forms, including reading-based discussions, case-based analysis, and simulation-based learning.⁷ Columbia University developed a pilot program of week-long didactic sessions that were delivered to third-year internal medicine residents. These seminars featured discussions on health policy and economics, health insurance, technology and cost assessment, legal medicine, public health, community-oriented primary care, and local health department initiatives.⁸ We drew on both courses to build a lecture series focused on the business of dermatology that was delivered to dermatology residents at UMass Chan Medical School (Worcester, Massachusetts). Topic selection also was informed by qualitative input collected via email from recent graduates of the UMass dermatology residency program, focusing on the following areas: the US medical economy and health care costs; billing, coding, and claims processing; quality, relative value units (RVUs), reimbursement, and the merit-based incentive payment system; coverage of pharmaceuticals and teledermatology; and management. Residents were not required to prepare for any of the sessions; they were provided with handouts and slideshow presentations for reference to review at their convenience if desired. Five seminars were virtually conducted by an MD/MBA candidate at the institution (E.H.). They were recorded over the course of an academic year at 1- to 2-month intervals. Each 45-minute session was conducted in a lecture-discussion format and included case examples to help illustrate key principles and stimulate conversation. For example, the lecture on reimbursement incorporated a fee schedule calculation for a shave biopsy, using RVU and geographic pricing cost index (GCPI) multipliers. This demonstrated the variation in Centers for Medicare & Medicaid Services reimbursement in relation to (1) constituents of the RVU calculation (ie, work, practice expense, and malpractice) and (2) practice in a particular location (ie, the GCPI). Following this example, a conversation ensued among participants regarding the factors that drive valuation, with particular interest in variation based on urban vs suburban locations across the United States. Participants also found it of interest to examine the percentage of the valuation dedicated to each constituent and how features such as lesion size informed the final assessment of the charge. Another stylistic choice in developing the model was to include prompts for further consideration prior to transitioning topics in the lectures. For example: when examining the burden of skin disease, the audience was prompted to consider: “What is driving cost escalations, and how will services of the clinical domain meet these evolving needs?” At another point in the introductory lecture, residents were asked: “How do different types of insurance plans impact the management of patients with dermatologic concerns?” These questions were intended to transition residents to the next topic of discussion and highlight take-home points of consideration for medical practice. The project was reviewed by the UMass institutional review board and met criteria for exemption.

Residents who participated in at least 1 lecture (N=10) were surveyed after attendance; there were 7 responses (70% response rate). Residents were asked to rate a series of statements on a scale of 1 (strongly disagree) to 5 (strongly agree) and to provide commentary via an online form. Respondents indicated that the course was enjoyable (average score, 4.00), provided an appropriate level of detail (average score, 4.00), would be beneficial to integrate into a dermatology residency curriculum (average score, 3.86), and informed how they would practice as a clinician (average score, 3.86)(Figure). The respondents agreed that the course met the main goals of this initiative: it helped them develop knowledge about the interface between business and dermatology (4.14) and exposed residents to topics they had not learned about previously (4.71).

Herringshaw.jpg

Although the course generally was well received, areas for improvement were identified from respondents’ comments, relating to audience engagement and refining the level of detail in the lectures. Recommendations included “less technical jargon and more focus on ‘big picture’ concepts, given audience’s low baseline knowledge”; “more case examples in each module”; and “more diagrams or interactive activities (polls, quizzes, break-out rooms) because the lectures were a bit dense.” This input was taken into consideration when revising the lectures for future use; they were reconstructed to have more case-based examples and prompts to encourage participation.

Resident commentary also demonstrated appreciation for education in this subject material. Statements such as “this is an important topic for future dermatologists” and “thank you so much for taking the time to implement this course” reflected the perceived value of this material during critical academic time. Another resident remarked: “This was great, thanks for putting it together.”

Given the positive experience of the residents and successful implementation of the series, this course was made available to all dermatology trainees on a network server with accompanying written documents. It is planned to be offered on a 3-year cycle in the future and will be updated to reflect inevitable changes in health care.

Although the relationship between business and medicine is increasingly important, teaching business principles has not become standardized or required in medical training. Despite the perception that this content is of value, implementation of programming has lagged behind that recognition, likely due to challenges in designing the curriculum and diffusing content into an already-saturated schedule. A model course that can be replicated in other residency programs would be valuable. We introduced a dermatology-specific lecture series to help prepare trainees for dermatology practice in a variety of clinical settings and train them with the language of business and operations that will equip them to respond to the needs of their patients, their practice, and the medical environment. Findings of this pilot study may not be generalizable to all dermatology residency programs because the sample size was small; the study was conducted at a single institution; and the content was delivered entirely online.

Similar to medical school, residency is a time to drink out of the proverbial firehose of knowledge. Along with clinical duties, there is a plethora of information ranging from clinical management decisions to boards fodder that dermatology residents are expected to know, leaving residents to adopt study habits from medical school. Flash cards remain a popular study tool in the medical education community. The use of Anki, a web-based and mobile flash card application (app) that features custom and premade flash card decks made and shared by users, has become increasingly popular. In a 2021 study, Lu et al¹ found that Anki flash card usage was associated with higher US Medical Licensing Examination scores. Herein, I provide an updated review of the top 3 most comprehensive premade Anki decks for dermatology residents, per my assessment.

COMPREHENSIVE DERMATOLOGY DECKS

Dolphin Dermatology

• Creator: Reddit user, Unknown²
• Date created: December 2020
• Last updated: April 2022
• Number of cards: 13,833
• Resources covered: Photographs of common dermatologic diagnoses from online sources such as VisualDx (https://www.visualdx.com/) and DermNet (https://dermnetnz.org/).
• Format of cards: One image or factoid per card.
• Card tags (allow separation of Anki decks into subcategories): Each general dermatology card is tagged by the diagnosis name. Pediatric dermatology cards are tagged by affected body location.
• Advantages: As you may glean by the sheer number of flash cards, this deck is a comprehensive review of clinical dermatology. Most cards feature clinical vignettes with clinical photographs of a dermatologic condition or histologic slide and ask what the diagnosis may be. It features photographs of pathology on a range of skin tones and many different images of each diagnosis. This is a great deck for residents who need to study clinical photographs of dermatologic diagnoses.
• Disadvantages: This deck does not cover dermatopathology, basic science, treatment options, or pharmacology in depth. Additionally, is difficult to find a link to download this resource.
• At the time of publication of this article, users are unable to download this deck.

vismo_djib’s Review of Dermatology Anki

• Creator: Reddit user vismo_djib³
• Date created: June 2020
• Last updated: February 2022
• Number of cards: 8454
• Resources covered: Alikhan and Hocker’s Review of Dermatology⁴ is the main resource with supplemental images from VisualDx, Bolognia et al’s Dermatology,⁵ Patterson’s Weedon’s Skin Pathology Essentials,⁶ Elston et al’s Dermatopathology,⁷ Soyer et al’s Dermoscopy: The Essentials,⁸ and Robinson et al’s Surgery of the Skin: Procedural Dermatology.⁹
• Format of cards: Cards mostly feature a diagnosis with color-coded categories including epidemiology, pathogenesis, clinical features, histopathology, and treatment.
• Card tags (allow separation of Anki decks into subcategories): Cards are tagged with chapter numbers from Alikhan and Hocker’s Review of Dermatology.⁴
• Advantages: This impressive comprehensive review of dermatology is a great option for residents studying for the American Board of Dermatology CORE examinations and users looking to solidify the information in Alikhan and Hocker’s Review of Dermatology,⁴ a frequently used resource among dermatology residents. It currently is my favorite deck because it features holistic information on diagnosis, epidemiology, pathogenesis, histopathology, and treatment with excellent clinical photographs.
• Disadvantages: For some purposes, this deck may be too lofty. For maximum benefit, it may require user customization including separating cards by tag and other add-ons that allow only 1 card per note, which will separate the information on each card into smaller increments. The mostly free-response format and lengthy slides may make it difficult to practice recall.

AnKingMed Dermki

• Creator: Reddit user AnKingMed^10,11
• Date created: April 2023
• Last updated: This deck features a dynamic add-on and collaboration application called AnkiHub, which allows for real-time updates. At the time this article was written, the deck was last updated on June 19, 2023.
• Number of cards: 7889
• Resources covered: Currently 75% of Alikhan and Hocker’s Review of Dermatology⁴ with supplemental images from DermNet and Eleryan and Friedman’s The Full Spectrum of Dermatology: A Diverse and Inclusive Atlas.¹²
• Format of cards: Cards are in a fill-in-the-blank format.
• Card tags (allow separation of Anki decks into subcategories): Cards are tagged by chapter number and subsection of Alikhan and Hocker’s Review of Dermatology.⁴
• Advantages: As the newest contribution to the dermatology Anki card compendium, this deck is up to date, innovative, and dynamic. It features an optional add-on application—AnkiHub—which allows users to keep up with live updates and collaborations. The deck features a fill-in-the-blank format that may be preferred to a free-response format for information recall. It features Alikhan and Hocker’s Review of Dermatology,⁴ which is a high-yield review of clinical dermatology, dermatopathology, surgical dermatology, pharmacology, and histopathology for dermatology residents.
• Disadvantages: The deck is still currently in a development phase, covering 75% of Alikhan and Hocker’s Review of Dermatology⁴ with plans to add the remaining 25%. The add-on to access the most up-to-date version of the flashcards requires a paid monthly or annual subscription; however, the creator announced they will release periodic free updates of the deck.

CT112001010_e_Table.jpg

Final Thoughts

As a collaborative platform, new flash card decks are always being added to Anki. This article is not comprehensive of all dermatologic flash card decks available. There are decks better suited for medical students covering topics such as the American Academy of Dermatology Basic Dermatology Curriculum, UWorld United States Medical Licensing Examination dermatology, and dermatology in internal medicine. Furthermore, specific study tools in dermatology may have their own accompanying Anki decks (ie, The Grenz Zone podcast, Dermnemonics). Flash cards can be a valuable study tool to trainees in medicine, and residents are immensely grateful to our peers who make them for our use.

Similar to medical school, residency is a time to drink out of the proverbial firehose of knowledge. Along with clinical duties, there is a plethora of information ranging from clinical management decisions to boards fodder that dermatology residents are expected to know, leaving residents to adopt study habits from medical school. Flash cards remain a popular study tool in the medical education community. The use of Anki, a web-based and mobile flash card application (app) that features custom and premade flash card decks made and shared by users, has become increasingly popular. In a 2021 study, Lu et al¹ found that Anki flash card usage was associated with higher US Medical Licensing Examination scores. Herein, I provide an updated review of the top 3 most comprehensive premade Anki decks for dermatology residents, per my assessment.

COMPREHENSIVE DERMATOLOGY DECKS

Dolphin Dermatology

• Creator: Reddit user, Unknown²
• Date created: December 2020
• Last updated: April 2022
• Number of cards: 13,833
• Resources covered: Photographs of common dermatologic diagnoses from online sources such as VisualDx (https://www.visualdx.com/) and DermNet (https://dermnetnz.org/).
• Format of cards: One image or factoid per card.
• Card tags (allow separation of Anki decks into subcategories): Each general dermatology card is tagged by the diagnosis name. Pediatric dermatology cards are tagged by affected body location.
• Advantages: As you may glean by the sheer number of flash cards, this deck is a comprehensive review of clinical dermatology. Most cards feature clinical vignettes with clinical photographs of a dermatologic condition or histologic slide and ask what the diagnosis may be. It features photographs of pathology on a range of skin tones and many different images of each diagnosis. This is a great deck for residents who need to study clinical photographs of dermatologic diagnoses.
• Disadvantages: This deck does not cover dermatopathology, basic science, treatment options, or pharmacology in depth. Additionally, is difficult to find a link to download this resource.
• At the time of publication of this article, users are unable to download this deck.

vismo_djib’s Review of Dermatology Anki

• Creator: Reddit user vismo_djib³
• Date created: June 2020
• Last updated: February 2022
• Number of cards: 8454
• Resources covered: Alikhan and Hocker’s Review of Dermatology⁴ is the main resource with supplemental images from VisualDx, Bolognia et al’s Dermatology,⁵ Patterson’s Weedon’s Skin Pathology Essentials,⁶ Elston et al’s Dermatopathology,⁷ Soyer et al’s Dermoscopy: The Essentials,⁸ and Robinson et al’s Surgery of the Skin: Procedural Dermatology.⁹
• Format of cards: Cards mostly feature a diagnosis with color-coded categories including epidemiology, pathogenesis, clinical features, histopathology, and treatment.
• Card tags (allow separation of Anki decks into subcategories): Cards are tagged with chapter numbers from Alikhan and Hocker’s Review of Dermatology.⁴
• Advantages: This impressive comprehensive review of dermatology is a great option for residents studying for the American Board of Dermatology CORE examinations and users looking to solidify the information in Alikhan and Hocker’s Review of Dermatology,⁴ a frequently used resource among dermatology residents. It currently is my favorite deck because it features holistic information on diagnosis, epidemiology, pathogenesis, histopathology, and treatment with excellent clinical photographs.
• Disadvantages: For some purposes, this deck may be too lofty. For maximum benefit, it may require user customization including separating cards by tag and other add-ons that allow only 1 card per note, which will separate the information on each card into smaller increments. The mostly free-response format and lengthy slides may make it difficult to practice recall.

AnKingMed Dermki

• Creator: Reddit user AnKingMed^10,11
• Date created: April 2023
• Last updated: This deck features a dynamic add-on and collaboration application called AnkiHub, which allows for real-time updates. At the time this article was written, the deck was last updated on June 19, 2023.
• Number of cards: 7889
• Resources covered: Currently 75% of Alikhan and Hocker’s Review of Dermatology⁴ with supplemental images from DermNet and Eleryan and Friedman’s The Full Spectrum of Dermatology: A Diverse and Inclusive Atlas.¹²
• Format of cards: Cards are in a fill-in-the-blank format.
• Card tags (allow separation of Anki decks into subcategories): Cards are tagged by chapter number and subsection of Alikhan and Hocker’s Review of Dermatology.⁴
• Advantages: As the newest contribution to the dermatology Anki card compendium, this deck is up to date, innovative, and dynamic. It features an optional add-on application—AnkiHub—which allows users to keep up with live updates and collaborations. The deck features a fill-in-the-blank format that may be preferred to a free-response format for information recall. It features Alikhan and Hocker’s Review of Dermatology,⁴ which is a high-yield review of clinical dermatology, dermatopathology, surgical dermatology, pharmacology, and histopathology for dermatology residents.
• Disadvantages: The deck is still currently in a development phase, covering 75% of Alikhan and Hocker’s Review of Dermatology⁴ with plans to add the remaining 25%. The add-on to access the most up-to-date version of the flashcards requires a paid monthly or annual subscription; however, the creator announced they will release periodic free updates of the deck.

CT112001010_e_Table.jpg

Final Thoughts

As a collaborative platform, new flash card decks are always being added to Anki. This article is not comprehensive of all dermatologic flash card decks available. There are decks better suited for medical students covering topics such as the American Academy of Dermatology Basic Dermatology Curriculum, UWorld United States Medical Licensing Examination dermatology, and dermatology in internal medicine. Furthermore, specific study tools in dermatology may have their own accompanying Anki decks (ie, The Grenz Zone podcast, Dermnemonics). Flash cards can be a valuable study tool to trainees in medicine, and residents are immensely grateful to our peers who make them for our use.

Similar to medical school, residency is a time to drink out of the proverbial firehose of knowledge. Along with clinical duties, there is a plethora of information ranging from clinical management decisions to boards fodder that dermatology residents are expected to know, leaving residents to adopt study habits from medical school. Flash cards remain a popular study tool in the medical education community. The use of Anki, a web-based and mobile flash card application (app) that features custom and premade flash card decks made and shared by users, has become increasingly popular. In a 2021 study, Lu et al¹ found that Anki flash card usage was associated with higher US Medical Licensing Examination scores. Herein, I provide an updated review of the top 3 most comprehensive premade Anki decks for dermatology residents, per my assessment.

COMPREHENSIVE DERMATOLOGY DECKS

Dolphin Dermatology

• Creator: Reddit user, Unknown²
• Date created: December 2020
• Last updated: April 2022
• Number of cards: 13,833
• Resources covered: Photographs of common dermatologic diagnoses from online sources such as VisualDx (https://www.visualdx.com/) and DermNet (https://dermnetnz.org/).
• Format of cards: One image or factoid per card.
• Card tags (allow separation of Anki decks into subcategories): Each general dermatology card is tagged by the diagnosis name. Pediatric dermatology cards are tagged by affected body location.
• Advantages: As you may glean by the sheer number of flash cards, this deck is a comprehensive review of clinical dermatology. Most cards feature clinical vignettes with clinical photographs of a dermatologic condition or histologic slide and ask what the diagnosis may be. It features photographs of pathology on a range of skin tones and many different images of each diagnosis. This is a great deck for residents who need to study clinical photographs of dermatologic diagnoses.
• Disadvantages: This deck does not cover dermatopathology, basic science, treatment options, or pharmacology in depth. Additionally, is difficult to find a link to download this resource.
• At the time of publication of this article, users are unable to download this deck.

vismo_djib’s Review of Dermatology Anki

• Creator: Reddit user vismo_djib³
• Date created: June 2020
• Last updated: February 2022
• Number of cards: 8454
• Resources covered: Alikhan and Hocker’s Review of Dermatology⁴ is the main resource with supplemental images from VisualDx, Bolognia et al’s Dermatology,⁵ Patterson’s Weedon’s Skin Pathology Essentials,⁶ Elston et al’s Dermatopathology,⁷ Soyer et al’s Dermoscopy: The Essentials,⁸ and Robinson et al’s Surgery of the Skin: Procedural Dermatology.⁹
• Format of cards: Cards mostly feature a diagnosis with color-coded categories including epidemiology, pathogenesis, clinical features, histopathology, and treatment.
• Card tags (allow separation of Anki decks into subcategories): Cards are tagged with chapter numbers from Alikhan and Hocker’s Review of Dermatology.⁴
• Advantages: This impressive comprehensive review of dermatology is a great option for residents studying for the American Board of Dermatology CORE examinations and users looking to solidify the information in Alikhan and Hocker’s Review of Dermatology,⁴ a frequently used resource among dermatology residents. It currently is my favorite deck because it features holistic information on diagnosis, epidemiology, pathogenesis, histopathology, and treatment with excellent clinical photographs.
• Disadvantages: For some purposes, this deck may be too lofty. For maximum benefit, it may require user customization including separating cards by tag and other add-ons that allow only 1 card per note, which will separate the information on each card into smaller increments. The mostly free-response format and lengthy slides may make it difficult to practice recall.

AnKingMed Dermki

• Creator: Reddit user AnKingMed^10,11
• Date created: April 2023
• Last updated: This deck features a dynamic add-on and collaboration application called AnkiHub, which allows for real-time updates. At the time this article was written, the deck was last updated on June 19, 2023.
• Number of cards: 7889
• Resources covered: Currently 75% of Alikhan and Hocker’s Review of Dermatology⁴ with supplemental images from DermNet and Eleryan and Friedman’s The Full Spectrum of Dermatology: A Diverse and Inclusive Atlas.¹²
• Format of cards: Cards are in a fill-in-the-blank format.
• Card tags (allow separation of Anki decks into subcategories): Cards are tagged by chapter number and subsection of Alikhan and Hocker’s Review of Dermatology.⁴
• Advantages: As the newest contribution to the dermatology Anki card compendium, this deck is up to date, innovative, and dynamic. It features an optional add-on application—AnkiHub—which allows users to keep up with live updates and collaborations. The deck features a fill-in-the-blank format that may be preferred to a free-response format for information recall. It features Alikhan and Hocker’s Review of Dermatology,⁴ which is a high-yield review of clinical dermatology, dermatopathology, surgical dermatology, pharmacology, and histopathology for dermatology residents.
• Disadvantages: The deck is still currently in a development phase, covering 75% of Alikhan and Hocker’s Review of Dermatology⁴ with plans to add the remaining 25%. The add-on to access the most up-to-date version of the flashcards requires a paid monthly or annual subscription; however, the creator announced they will release periodic free updates of the deck.

CT112001010_e_Table.jpg

Final Thoughts

As a collaborative platform, new flash card decks are always being added to Anki. This article is not comprehensive of all dermatologic flash card decks available. There are decks better suited for medical students covering topics such as the American Academy of Dermatology Basic Dermatology Curriculum, UWorld United States Medical Licensing Examination dermatology, and dermatology in internal medicine. Furthermore, specific study tools in dermatology may have their own accompanying Anki decks (ie, The Grenz Zone podcast, Dermnemonics). Flash cards can be a valuable study tool to trainees in medicine, and residents are immensely grateful to our peers who make them for our use.

In March 2020, as I was wheeling my patient into the operating room to perform a Caesarean section, covered head-to-toe in COVID personal protective equipment, my phone rang. It was Jody Schindelheim, MD, Director of the Psychiatry Residency Program at Tufts Medical Center in Boston, calling to offer me a PGY-2 spot in their program.

As COVID upended the world, I was struggling with my own major change. My path had been planned since before medical school: I would grind through a 4-year OB/GYN residency, complete a fellowship, and establish myself as a reproductive endocrinology and infertility specialist. My personal statement emphasized my dream that no woman should be made to feel useless based on infertility. OB/GYN, genetics, and ultrasound were my favorite rotations at the Albert Einstein College of Medicine in the Bronx.

However, 6 months into my OB/GYN intern year, I grew curious about the possibility of a future in reproductive psychiatry and women’s mental health. This decision was not easy. As someone who loved the adrenaline rush of delivering babies and performing surgery, I had paid little attention to psychiatry in medical school. However, my experience in gynecologic oncology in January 2020 made me realize my love of stories and trauma-informed care. I recall a woman, cachectic with only days left to live due to ovarian cancer, talking to me about her trauma and the power of her lifelong partner. Another woman, experiencing complications from chemotherapy to treat fallopian tube cancer, shared about her coping skill of chair yoga.

Fulfilling an unmet need

As I spent time with these 2 women and heard their stories, I felt compelled to help them with these psychological challenges. As a gynecologist, I addressed their physical needs, but not their personal needs. I spoke to many psychiatrists, including reproductive psychiatrists, in New York, who shared their stories and taught me about the prevalence of postpartum depression and psychosis. After caring for hundreds of pregnant and postpartum women in the Bronx, I thought about the unmet need for women’s mental health and how this career change could still fulfill my purpose of helping women feel empowered regardless of their fertility status.

In the inpatient and outpatient settings at Tufts, I have loved hearing my patients’ stories and providing continuity of care with medical management and therapy. My mentors in reproductive psychiatry inspired me to create the Reproductive Psychiatry Trainee Interest Group (https://www.repropsychtrainees.com), a national group for the burgeoning field that now has more than 650 members. With monthly lectures, journal clubs, and book clubs, I have surrounded myself with like-minded individuals who love learning about the perinatal, postpartum, and perimenopausal experiences.

As I prepare to begin a full-time faculty position in psychiatry at the University of Pennsylvania, I know I have found my joy and my calling. I once feared the life of a psychiatrist would be too sedentary for someone accustomed to the pace of OB/GYN. Now I know that my patients’ stories are all the motivation I need.

In March 2020, as I was wheeling my patient into the operating room to perform a Caesarean section, covered head-to-toe in COVID personal protective equipment, my phone rang. It was Jody Schindelheim, MD, Director of the Psychiatry Residency Program at Tufts Medical Center in Boston, calling to offer me a PGY-2 spot in their program.

As COVID upended the world, I was struggling with my own major change. My path had been planned since before medical school: I would grind through a 4-year OB/GYN residency, complete a fellowship, and establish myself as a reproductive endocrinology and infertility specialist. My personal statement emphasized my dream that no woman should be made to feel useless based on infertility. OB/GYN, genetics, and ultrasound were my favorite rotations at the Albert Einstein College of Medicine in the Bronx.

However, 6 months into my OB/GYN intern year, I grew curious about the possibility of a future in reproductive psychiatry and women’s mental health. This decision was not easy. As someone who loved the adrenaline rush of delivering babies and performing surgery, I had paid little attention to psychiatry in medical school. However, my experience in gynecologic oncology in January 2020 made me realize my love of stories and trauma-informed care. I recall a woman, cachectic with only days left to live due to ovarian cancer, talking to me about her trauma and the power of her lifelong partner. Another woman, experiencing complications from chemotherapy to treat fallopian tube cancer, shared about her coping skill of chair yoga.

Fulfilling an unmet need

As I spent time with these 2 women and heard their stories, I felt compelled to help them with these psychological challenges. As a gynecologist, I addressed their physical needs, but not their personal needs. I spoke to many psychiatrists, including reproductive psychiatrists, in New York, who shared their stories and taught me about the prevalence of postpartum depression and psychosis. After caring for hundreds of pregnant and postpartum women in the Bronx, I thought about the unmet need for women’s mental health and how this career change could still fulfill my purpose of helping women feel empowered regardless of their fertility status.

In the inpatient and outpatient settings at Tufts, I have loved hearing my patients’ stories and providing continuity of care with medical management and therapy. My mentors in reproductive psychiatry inspired me to create the Reproductive Psychiatry Trainee Interest Group (https://www.repropsychtrainees.com), a national group for the burgeoning field that now has more than 650 members. With monthly lectures, journal clubs, and book clubs, I have surrounded myself with like-minded individuals who love learning about the perinatal, postpartum, and perimenopausal experiences.

As I prepare to begin a full-time faculty position in psychiatry at the University of Pennsylvania, I know I have found my joy and my calling. I once feared the life of a psychiatrist would be too sedentary for someone accustomed to the pace of OB/GYN. Now I know that my patients’ stories are all the motivation I need.

In March 2020, as I was wheeling my patient into the operating room to perform a Caesarean section, covered head-to-toe in COVID personal protective equipment, my phone rang. It was Jody Schindelheim, MD, Director of the Psychiatry Residency Program at Tufts Medical Center in Boston, calling to offer me a PGY-2 spot in their program.

As COVID upended the world, I was struggling with my own major change. My path had been planned since before medical school: I would grind through a 4-year OB/GYN residency, complete a fellowship, and establish myself as a reproductive endocrinology and infertility specialist. My personal statement emphasized my dream that no woman should be made to feel useless based on infertility. OB/GYN, genetics, and ultrasound were my favorite rotations at the Albert Einstein College of Medicine in the Bronx.

However, 6 months into my OB/GYN intern year, I grew curious about the possibility of a future in reproductive psychiatry and women’s mental health. This decision was not easy. As someone who loved the adrenaline rush of delivering babies and performing surgery, I had paid little attention to psychiatry in medical school. However, my experience in gynecologic oncology in January 2020 made me realize my love of stories and trauma-informed care. I recall a woman, cachectic with only days left to live due to ovarian cancer, talking to me about her trauma and the power of her lifelong partner. Another woman, experiencing complications from chemotherapy to treat fallopian tube cancer, shared about her coping skill of chair yoga.

Fulfilling an unmet need

As I spent time with these 2 women and heard their stories, I felt compelled to help them with these psychological challenges. As a gynecologist, I addressed their physical needs, but not their personal needs. I spoke to many psychiatrists, including reproductive psychiatrists, in New York, who shared their stories and taught me about the prevalence of postpartum depression and psychosis. After caring for hundreds of pregnant and postpartum women in the Bronx, I thought about the unmet need for women’s mental health and how this career change could still fulfill my purpose of helping women feel empowered regardless of their fertility status.

In the inpatient and outpatient settings at Tufts, I have loved hearing my patients’ stories and providing continuity of care with medical management and therapy. My mentors in reproductive psychiatry inspired me to create the Reproductive Psychiatry Trainee Interest Group (https://www.repropsychtrainees.com), a national group for the burgeoning field that now has more than 650 members. With monthly lectures, journal clubs, and book clubs, I have surrounded myself with like-minded individuals who love learning about the perinatal, postpartum, and perimenopausal experiences.

As I prepare to begin a full-time faculty position in psychiatry at the University of Pennsylvania, I know I have found my joy and my calling. I once feared the life of a psychiatrist would be too sedentary for someone accustomed to the pace of OB/GYN. Now I know that my patients’ stories are all the motivation I need.

To the Editor:

Dermatology is one of the most competitive residencies for matching, with a 57.5% match rate in 2022.¹ Our prior study of research-mentor relationships among matched dermatology applicants corroborated the importance of home programs (HPs) and program connections.² Therefore, our current objective was to compare profiles of matched dermatology applicants without HPs vs those with HPs.

We searched websites of 139 dermatology programs nationwide and found 1736 matched applicants from 2016 to 2020; of them, 323 did not have HPs. We determined program rank by research output using Doximity Residency Navigator (https://www.doximity.com/residency/). Advanced degrees (ADs) of applicants were identified using program websites and LinkedIn. A PubMed search was conducted for number of articles published by each applicant before September 15 of their match year. For applicants without HPs, we identified the senior author on each publication. The senior author publishing with an applicant most often was considered the research mentor. Two-tailed independent t tests and χ² tests were used to determine statistical significance (P<.05).

On average, matched applicants without HPs matched in lower-ranked (74.4) and smaller (12.4) programs compared with matched applicants with HPs (45.3 [P<.0001] and 15.1 [P<.0001], respectively)(eTable). The mean number of publications was similar between matched applicants with HPs and without HPs (5.64 and 4.80, respectively; P=.0525) as well as the percentage with ADs (14.7% and 11.5%, respectively; P=.0953). Overall, 14.8% of matched applicants without HPs matched at their mentors’ institutions.

CT111006291_eTable.jpg

Data were obtained for matched international applicants as a subset of non-HP applicants. Despite attending medical schools without associated HPs in the United States, international applicants matched at similarly ranked (44.3) and sized (15.0) programs, on average, compared with HP applicants. The mean number of publications was higher for international applicants (11.4) vs domestic applicants (5.33). International applicants more often had ADs (23.8%) and 60.1% of them held doctor of philosophy degrees. Overall, 40.5% of international applicants matched at their mentors’ institutions.

Our study suggests that matched dermatology applicants with and without HPs had similar achievements, on average, for the number of publications and percentage with ADs. However, non-HP applicants matched at lower-ranked programs than HP applicants. Therefore, applicants without HPs should strongly consider cultivating program connections, especially if they desire to match at higher-ranked dermatology programs. To illustrate, the rate of matching at research mentors’ institutions was approximately 3-times higher for international applicants than non-HP applicants overall. Despite the disadvantages of applying as international applicants, they were able to match at substantially higher-ranked dermatology programs than non-HP applicants. International applicants may have a longer time investment—the number of years from obtaining their medical degree or US medical license to matching—giving them time to produce quality research and develop meaningful relationships at an institution. Additionally, our prior study of the top 25 dermatology residencies showed that 26.2% of successful applicants matched at their research mentors’ institutions, with almost half of this subset matching at their HPs, where their mentors also practiced.² Because of the potential benefits of having program connections, applicants without HPs should seek dermatology research mentors, especially via highly beneficial in-person networking opportunities (eg, away rotations, conferences) that had previously been limited during the COVID-19 pandemic.³ Formal mentorship programs giving priority to students without HPs recently have been developed, which only begins to address the inequities in the dermatology residency application process.⁴

Study limitations include lack of resident information on 15 program websites, missed publications due to applicant name changes, not accounting for abstracts and posters, and inability to collect data on unmatched applicants.

We hope that our study alleviates some concerns that applicants without HPs may have regarding applying for dermatology residency and encourages those with a genuine interest in dermatology to pursue the specialty, provided they find a strong research mentor. Residency programs should be cognizant of the unique challenges that non-HP applicants face for matching.

To the Editor:

Dermatology is one of the most competitive residencies for matching, with a 57.5% match rate in 2022.¹ Our prior study of research-mentor relationships among matched dermatology applicants corroborated the importance of home programs (HPs) and program connections.² Therefore, our current objective was to compare profiles of matched dermatology applicants without HPs vs those with HPs.

We searched websites of 139 dermatology programs nationwide and found 1736 matched applicants from 2016 to 2020; of them, 323 did not have HPs. We determined program rank by research output using Doximity Residency Navigator (https://www.doximity.com/residency/). Advanced degrees (ADs) of applicants were identified using program websites and LinkedIn. A PubMed search was conducted for number of articles published by each applicant before September 15 of their match year. For applicants without HPs, we identified the senior author on each publication. The senior author publishing with an applicant most often was considered the research mentor. Two-tailed independent t tests and χ² tests were used to determine statistical significance (P<.05).

On average, matched applicants without HPs matched in lower-ranked (74.4) and smaller (12.4) programs compared with matched applicants with HPs (45.3 [P<.0001] and 15.1 [P<.0001], respectively)(eTable). The mean number of publications was similar between matched applicants with HPs and without HPs (5.64 and 4.80, respectively; P=.0525) as well as the percentage with ADs (14.7% and 11.5%, respectively; P=.0953). Overall, 14.8% of matched applicants without HPs matched at their mentors’ institutions.

CT111006291_eTable.jpg

Data were obtained for matched international applicants as a subset of non-HP applicants. Despite attending medical schools without associated HPs in the United States, international applicants matched at similarly ranked (44.3) and sized (15.0) programs, on average, compared with HP applicants. The mean number of publications was higher for international applicants (11.4) vs domestic applicants (5.33). International applicants more often had ADs (23.8%) and 60.1% of them held doctor of philosophy degrees. Overall, 40.5% of international applicants matched at their mentors’ institutions.

Our study suggests that matched dermatology applicants with and without HPs had similar achievements, on average, for the number of publications and percentage with ADs. However, non-HP applicants matched at lower-ranked programs than HP applicants. Therefore, applicants without HPs should strongly consider cultivating program connections, especially if they desire to match at higher-ranked dermatology programs. To illustrate, the rate of matching at research mentors’ institutions was approximately 3-times higher for international applicants than non-HP applicants overall. Despite the disadvantages of applying as international applicants, they were able to match at substantially higher-ranked dermatology programs than non-HP applicants. International applicants may have a longer time investment—the number of years from obtaining their medical degree or US medical license to matching—giving them time to produce quality research and develop meaningful relationships at an institution. Additionally, our prior study of the top 25 dermatology residencies showed that 26.2% of successful applicants matched at their research mentors’ institutions, with almost half of this subset matching at their HPs, where their mentors also practiced.² Because of the potential benefits of having program connections, applicants without HPs should seek dermatology research mentors, especially via highly beneficial in-person networking opportunities (eg, away rotations, conferences) that had previously been limited during the COVID-19 pandemic.³ Formal mentorship programs giving priority to students without HPs recently have been developed, which only begins to address the inequities in the dermatology residency application process.⁴

Study limitations include lack of resident information on 15 program websites, missed publications due to applicant name changes, not accounting for abstracts and posters, and inability to collect data on unmatched applicants.

We hope that our study alleviates some concerns that applicants without HPs may have regarding applying for dermatology residency and encourages those with a genuine interest in dermatology to pursue the specialty, provided they find a strong research mentor. Residency programs should be cognizant of the unique challenges that non-HP applicants face for matching.

To the Editor:

Dermatology is one of the most competitive residencies for matching, with a 57.5% match rate in 2022.¹ Our prior study of research-mentor relationships among matched dermatology applicants corroborated the importance of home programs (HPs) and program connections.² Therefore, our current objective was to compare profiles of matched dermatology applicants without HPs vs those with HPs.

We searched websites of 139 dermatology programs nationwide and found 1736 matched applicants from 2016 to 2020; of them, 323 did not have HPs. We determined program rank by research output using Doximity Residency Navigator (https://www.doximity.com/residency/). Advanced degrees (ADs) of applicants were identified using program websites and LinkedIn. A PubMed search was conducted for number of articles published by each applicant before September 15 of their match year. For applicants without HPs, we identified the senior author on each publication. The senior author publishing with an applicant most often was considered the research mentor. Two-tailed independent t tests and χ² tests were used to determine statistical significance (P<.05).

On average, matched applicants without HPs matched in lower-ranked (74.4) and smaller (12.4) programs compared with matched applicants with HPs (45.3 [P<.0001] and 15.1 [P<.0001], respectively)(eTable). The mean number of publications was similar between matched applicants with HPs and without HPs (5.64 and 4.80, respectively; P=.0525) as well as the percentage with ADs (14.7% and 11.5%, respectively; P=.0953). Overall, 14.8% of matched applicants without HPs matched at their mentors’ institutions.

CT111006291_eTable.jpg

Data were obtained for matched international applicants as a subset of non-HP applicants. Despite attending medical schools without associated HPs in the United States, international applicants matched at similarly ranked (44.3) and sized (15.0) programs, on average, compared with HP applicants. The mean number of publications was higher for international applicants (11.4) vs domestic applicants (5.33). International applicants more often had ADs (23.8%) and 60.1% of them held doctor of philosophy degrees. Overall, 40.5% of international applicants matched at their mentors’ institutions.

Our study suggests that matched dermatology applicants with and without HPs had similar achievements, on average, for the number of publications and percentage with ADs. However, non-HP applicants matched at lower-ranked programs than HP applicants. Therefore, applicants without HPs should strongly consider cultivating program connections, especially if they desire to match at higher-ranked dermatology programs. To illustrate, the rate of matching at research mentors’ institutions was approximately 3-times higher for international applicants than non-HP applicants overall. Despite the disadvantages of applying as international applicants, they were able to match at substantially higher-ranked dermatology programs than non-HP applicants. International applicants may have a longer time investment—the number of years from obtaining their medical degree or US medical license to matching—giving them time to produce quality research and develop meaningful relationships at an institution. Additionally, our prior study of the top 25 dermatology residencies showed that 26.2% of successful applicants matched at their research mentors’ institutions, with almost half of this subset matching at their HPs, where their mentors also practiced.² Because of the potential benefits of having program connections, applicants without HPs should seek dermatology research mentors, especially via highly beneficial in-person networking opportunities (eg, away rotations, conferences) that had previously been limited during the COVID-19 pandemic.³ Formal mentorship programs giving priority to students without HPs recently have been developed, which only begins to address the inequities in the dermatology residency application process.⁴

Study limitations include lack of resident information on 15 program websites, missed publications due to applicant name changes, not accounting for abstracts and posters, and inability to collect data on unmatched applicants.

We hope that our study alleviates some concerns that applicants without HPs may have regarding applying for dermatology residency and encourages those with a genuine interest in dermatology to pursue the specialty, provided they find a strong research mentor. Residency programs should be cognizant of the unique challenges that non-HP applicants face for matching.

Medical students often perform away rotations (also called visiting electives) to gain exposure to educational experiences in a particular specialty, learn about a program, and show interest in a certain program. Away rotations also allow applicants to meet and form relationships with mentors and faculty outside of their home institution. For residency programs, away rotations provide an opportunity for a holistic review of applicants by allowing program directors to get to know potential residency applicants and assess their performance in the clinical environment and among the program’s team. In a National Resident Matching Program survey, program directors (n=17) reported that prior knowledge of an applicant is an important factor in selecting applicants to interview (82.4%) and rank (58.8%).¹

In this article, we discuss the importance of away rotations in dermatology and provide an overview of the Organization of Program Director Associations (OPDA) and Association of Professors of Dermatology (APD) guidelines for away rotations.

Importance of the Away Rotation in the Match

According to the Association of American Medical Colleges, 86.7% of dermatology applicants (N=345) completed one or more away rotations (mean, 2.7) in 2020.² Winterton et al³ reported that 47% of dermatology applicants (N=45) matched at a program where they completed an away rotation. Prior to the COVID-19 pandemic, the number of applicants matching to their home program was reported as 26.7% (N=641), which jumped to 40.3% (N=231) in the 2020-2021 cycle.⁴ Given that the majority of dermatology applicants reportedly match either at their home program or at programs where they completed an away rotation, the benefits of away rotations are high, particularly in a competitive specialty such as dermatology and particularly for applicants without a dermatology program at their home institution. However, it must be acknowledged that correlation does not necessarily mean causation, as away rotations have not necessarily been shown to increase applicants’ chances of matching for the most competitive specialties.⁵

OPDA Guidelines for Away Rotations

In 2021, the Coalition of Physician Accountability’s Undergraduate Medical Education-Graduate Medical Education Review Committee recommended creating a workgroup to explore the function and value of away rotations for medical students, programs, and institutions, with a particular focus on issues of equity (eg, accessibility, assessment, opportunity) for underrepresented in medicine students and those with financial disadvantages.⁶ The OPDA workgroup evaluated the advantages and disadvantages of away rotations across specialties. The disadvantages included that away rotations may decrease resources to students at their own institution, particularly if faculty time and energy are funneled/dedicated to away rotators instead of internal rotators, and may impart bias into the recruitment process. Additionally, there is a consideration of equity given the considerable cost and time commitment of travel and housing for students at another institution. In 2022, the estimated cost of an away rotation in dermatology ranged from $1390 to $5500 per rotation.⁷ Visiting scholarships may be available at some institutions but typically are reserved for underrepresented in medicine students.⁸ Virtual rotations offered at some programs offset the cost-prohibitiveness of an in-person away rotation; however, they are not universally offered and may be limited in allowing for meaningful interactions between students and program faculty and residents.

The OPDA away rotation workgroup recommended that (1) each specialty publish guidelines regarding the necessity and number of recommended away rotations; (2) specialties publish explicit language regarding the use of program preference signals to programs where students rotated; (3) programs be transparent about the purpose and value of an away rotation, including explicitly stating whether a formal interview is guaranteed; and (4) the Association of American Medical Colleges create a repository of these specialty-specific recommendations.⁹

APD Guidelines for Away Rotations

In response to the OPDA recommendations, the APD Residency Program Directors Section developed dermatology-specific guidelines for away rotations and established guidelines in other specialties.¹⁰ The APD recommends completing up to 2 away rotations, or 3 for those without a home program, if desired. This number was chosen in acknowledgment of the importance of external program experiences, along with the recognition of the financial and time restrictions associated with away rotations as well as the limited number of spots for rotating students. Away rotations are not mandatory. The APD guidelines explain the purpose and value of an away rotation while also noting that these rotations do not necessarily guarantee a formal interview and recommending that programs be transparent about their policies on interview invitations, which may vary.¹⁰

Final Thoughts

Publishing specialty-specific guidelines on away rotations is one step toward streamlining the process as well as increasing transparency on the importance of these external program experiences in the application process and residency match. Ideally, away rotations provide a valuable educational experience in which students and program directors get to know each other in a mutually beneficial manner; however, away rotations are not required for securing an interview or matching at a program, and there also are recognized disadvantages to away rotations, particularly with regard to equity, that we must continue to weigh as a specialty. The APD will continue its collaborative work to evaluate our application processes to support a sustainable and equitable system.

Medical students often perform away rotations (also called visiting electives) to gain exposure to educational experiences in a particular specialty, learn about a program, and show interest in a certain program. Away rotations also allow applicants to meet and form relationships with mentors and faculty outside of their home institution. For residency programs, away rotations provide an opportunity for a holistic review of applicants by allowing program directors to get to know potential residency applicants and assess their performance in the clinical environment and among the program’s team. In a National Resident Matching Program survey, program directors (n=17) reported that prior knowledge of an applicant is an important factor in selecting applicants to interview (82.4%) and rank (58.8%).¹

In this article, we discuss the importance of away rotations in dermatology and provide an overview of the Organization of Program Director Associations (OPDA) and Association of Professors of Dermatology (APD) guidelines for away rotations.

Importance of the Away Rotation in the Match

According to the Association of American Medical Colleges, 86.7% of dermatology applicants (N=345) completed one or more away rotations (mean, 2.7) in 2020.² Winterton et al³ reported that 47% of dermatology applicants (N=45) matched at a program where they completed an away rotation. Prior to the COVID-19 pandemic, the number of applicants matching to their home program was reported as 26.7% (N=641), which jumped to 40.3% (N=231) in the 2020-2021 cycle.⁴ Given that the majority of dermatology applicants reportedly match either at their home program or at programs where they completed an away rotation, the benefits of away rotations are high, particularly in a competitive specialty such as dermatology and particularly for applicants without a dermatology program at their home institution. However, it must be acknowledged that correlation does not necessarily mean causation, as away rotations have not necessarily been shown to increase applicants’ chances of matching for the most competitive specialties.⁵

OPDA Guidelines for Away Rotations

In 2021, the Coalition of Physician Accountability’s Undergraduate Medical Education-Graduate Medical Education Review Committee recommended creating a workgroup to explore the function and value of away rotations for medical students, programs, and institutions, with a particular focus on issues of equity (eg, accessibility, assessment, opportunity) for underrepresented in medicine students and those with financial disadvantages.⁶ The OPDA workgroup evaluated the advantages and disadvantages of away rotations across specialties. The disadvantages included that away rotations may decrease resources to students at their own institution, particularly if faculty time and energy are funneled/dedicated to away rotators instead of internal rotators, and may impart bias into the recruitment process. Additionally, there is a consideration of equity given the considerable cost and time commitment of travel and housing for students at another institution. In 2022, the estimated cost of an away rotation in dermatology ranged from $1390 to $5500 per rotation.⁷ Visiting scholarships may be available at some institutions but typically are reserved for underrepresented in medicine students.⁸ Virtual rotations offered at some programs offset the cost-prohibitiveness of an in-person away rotation; however, they are not universally offered and may be limited in allowing for meaningful interactions between students and program faculty and residents.

The OPDA away rotation workgroup recommended that (1) each specialty publish guidelines regarding the necessity and number of recommended away rotations; (2) specialties publish explicit language regarding the use of program preference signals to programs where students rotated; (3) programs be transparent about the purpose and value of an away rotation, including explicitly stating whether a formal interview is guaranteed; and (4) the Association of American Medical Colleges create a repository of these specialty-specific recommendations.⁹

APD Guidelines for Away Rotations

In response to the OPDA recommendations, the APD Residency Program Directors Section developed dermatology-specific guidelines for away rotations and established guidelines in other specialties.¹⁰ The APD recommends completing up to 2 away rotations, or 3 for those without a home program, if desired. This number was chosen in acknowledgment of the importance of external program experiences, along with the recognition of the financial and time restrictions associated with away rotations as well as the limited number of spots for rotating students. Away rotations are not mandatory. The APD guidelines explain the purpose and value of an away rotation while also noting that these rotations do not necessarily guarantee a formal interview and recommending that programs be transparent about their policies on interview invitations, which may vary.¹⁰

Final Thoughts

Publishing specialty-specific guidelines on away rotations is one step toward streamlining the process as well as increasing transparency on the importance of these external program experiences in the application process and residency match. Ideally, away rotations provide a valuable educational experience in which students and program directors get to know each other in a mutually beneficial manner; however, away rotations are not required for securing an interview or matching at a program, and there also are recognized disadvantages to away rotations, particularly with regard to equity, that we must continue to weigh as a specialty. The APD will continue its collaborative work to evaluate our application processes to support a sustainable and equitable system.

Medical students often perform away rotations (also called visiting electives) to gain exposure to educational experiences in a particular specialty, learn about a program, and show interest in a certain program. Away rotations also allow applicants to meet and form relationships with mentors and faculty outside of their home institution. For residency programs, away rotations provide an opportunity for a holistic review of applicants by allowing program directors to get to know potential residency applicants and assess their performance in the clinical environment and among the program’s team. In a National Resident Matching Program survey, program directors (n=17) reported that prior knowledge of an applicant is an important factor in selecting applicants to interview (82.4%) and rank (58.8%).¹

In this article, we discuss the importance of away rotations in dermatology and provide an overview of the Organization of Program Director Associations (OPDA) and Association of Professors of Dermatology (APD) guidelines for away rotations.

Importance of the Away Rotation in the Match

According to the Association of American Medical Colleges, 86.7% of dermatology applicants (N=345) completed one or more away rotations (mean, 2.7) in 2020.² Winterton et al³ reported that 47% of dermatology applicants (N=45) matched at a program where they completed an away rotation. Prior to the COVID-19 pandemic, the number of applicants matching to their home program was reported as 26.7% (N=641), which jumped to 40.3% (N=231) in the 2020-2021 cycle.⁴ Given that the majority of dermatology applicants reportedly match either at their home program or at programs where they completed an away rotation, the benefits of away rotations are high, particularly in a competitive specialty such as dermatology and particularly for applicants without a dermatology program at their home institution. However, it must be acknowledged that correlation does not necessarily mean causation, as away rotations have not necessarily been shown to increase applicants’ chances of matching for the most competitive specialties.⁵

OPDA Guidelines for Away Rotations

In 2021, the Coalition of Physician Accountability’s Undergraduate Medical Education-Graduate Medical Education Review Committee recommended creating a workgroup to explore the function and value of away rotations for medical students, programs, and institutions, with a particular focus on issues of equity (eg, accessibility, assessment, opportunity) for underrepresented in medicine students and those with financial disadvantages.⁶ The OPDA workgroup evaluated the advantages and disadvantages of away rotations across specialties. The disadvantages included that away rotations may decrease resources to students at their own institution, particularly if faculty time and energy are funneled/dedicated to away rotators instead of internal rotators, and may impart bias into the recruitment process. Additionally, there is a consideration of equity given the considerable cost and time commitment of travel and housing for students at another institution. In 2022, the estimated cost of an away rotation in dermatology ranged from $1390 to $5500 per rotation.⁷ Visiting scholarships may be available at some institutions but typically are reserved for underrepresented in medicine students.⁸ Virtual rotations offered at some programs offset the cost-prohibitiveness of an in-person away rotation; however, they are not universally offered and may be limited in allowing for meaningful interactions between students and program faculty and residents.

The OPDA away rotation workgroup recommended that (1) each specialty publish guidelines regarding the necessity and number of recommended away rotations; (2) specialties publish explicit language regarding the use of program preference signals to programs where students rotated; (3) programs be transparent about the purpose and value of an away rotation, including explicitly stating whether a formal interview is guaranteed; and (4) the Association of American Medical Colleges create a repository of these specialty-specific recommendations.⁹

APD Guidelines for Away Rotations

In response to the OPDA recommendations, the APD Residency Program Directors Section developed dermatology-specific guidelines for away rotations and established guidelines in other specialties.¹⁰ The APD recommends completing up to 2 away rotations, or 3 for those without a home program, if desired. This number was chosen in acknowledgment of the importance of external program experiences, along with the recognition of the financial and time restrictions associated with away rotations as well as the limited number of spots for rotating students. Away rotations are not mandatory. The APD guidelines explain the purpose and value of an away rotation while also noting that these rotations do not necessarily guarantee a formal interview and recommending that programs be transparent about their policies on interview invitations, which may vary.¹⁰

Final Thoughts

Publishing specialty-specific guidelines on away rotations is one step toward streamlining the process as well as increasing transparency on the importance of these external program experiences in the application process and residency match. Ideally, away rotations provide a valuable educational experience in which students and program directors get to know each other in a mutually beneficial manner; however, away rotations are not required for securing an interview or matching at a program, and there also are recognized disadvantages to away rotations, particularly with regard to equity, that we must continue to weigh as a specialty. The APD will continue its collaborative work to evaluate our application processes to support a sustainable and equitable system.

Patients are finding it easier to use online resources to discover health care providers who fit their personalized needs. In the United States, approximately 70% of individuals use the internet to find health care information, and 80% are influenced by the information presented to them on health care websites.¹ Patients utilize the internet to better understand treatments offered by providers and their prices as well as how other patients have rated their experience. Providers in private practice also have noticed that many patients are referring themselves vs obtaining a referral from another provider.² As a result, it is critical for practice websites to have information that is of value to their patients, including the unique qualities and treatments offered. The purpose of this study was to analyze the differences between the content presented on dermatology private practice websites and academic institutional websites.

Methods

Websites Searched —All 140 academic dermatology programs, including both allopathic and osteopathic programs, were queried from the Association of American Medical Colleges (AAMC) database in March 2022. ³ First, the dermatology departmental websites for each program were analyzed to see if they contained information pertinent to patients. Any website that lacked this information or only had information relevant to the dermatology residency program was excluded from the study. After exclusion, a total of 113 websites were used in the academic website cohort. The private practices were found through an incognito Google search with the search term dermatologist and matched to be within 5 miles of each academic institution. The private practices that included at least one board-certified dermatologist and received the highest number of reviews on Google compared to other practices in the same region—a measure of online reputation—were selected to be in the private practice cohort (N = 113). Any duplicate practices, practices belonging to the same conglomerate company, or multispecialty clinics were excluded from the study. Board-certified dermatologists were confirmed using the Find a Dermatologist tool on the American Academy of Dermatology (AAD) website. ⁴

Website Assessments —Each website was assessed using 23 criteria divided into 4 categories: practice, physician(s), patient, and treatment/procedure (Table). Criteria for social media and publicity were further assessed. Criteria for social media included links on the website to a Facebook page, an Instagram account, a Twitter account, a Pinterest account, a LinkedIn account, a blog, a Yelp page, a YouTube channel, and/or any other social media. Criteria for publicity included links on the website to local television news, national news, newspapers, and/or magazines. ^5-8 Ease of site access was determined if the website was the first search result found on Google when searching for each website. Nondermatology professionals included listing of mid-level providers or researchers.

CT111006297_Table.jpg

Four individuals (V.S.J., A.C.B., M.E.O., and M.B.B.) independently assessed each of the websites using the established criteria. Each criterion was defined and discussed prior to data collection to maintain consistency. The criteria were determined as being present if the website clearly displayed, stated, explained, or linked to the relevant content. If the website did not directly contain the content, it was determined that the criteria were absent. One other individual (J.P.) independently cross-examined the data for consistency and evaluated for any discrepancies. ⁸

A raw analysis was done between each cohort. Another analysis was done that controlled for population density and the proportionate population age in each city ⁹ in which an academic institution/private practice was located. We proposed that more densely populated cities naturally may have more competition between practices, which may result in more optimized websites. ¹⁰ We also anticipated similar findings in cities with younger populations, as the younger demographic may be more likely to utilize and value online information when compared to older populations. ¹¹ The websites for each cohort were equally divided into 3 tiers of population density (not shown) and population age (not shown).

Statistical Analysis —Statistical analysis was completed using descriptive statistics, χ ² testing, and Fisher exact tests where appropriate with a predetermined level of significance of P < .05 in Microsoft Excel.

Results

Demographics —A total of 226 websites from both private practices and academic institutions were evaluated. Of them, only 108 private practices and 108 academic institutions listed practicing dermatologists on their site. Of 108 private practices, 76 (70.4%) had more than one practicing board-certified dermatologist. Of 108 academic institutions, all 108 (100%) institutions had more than one practicing board-certified dermatologist.

Of the dermatologists who practiced at academic institutions (n=2014) and private practices (n=817), 1157 (57.4%) and 419 (51.2%) were females, respectively. The population density of the cities with each of these practices/institutions ranged from 137 individuals per square kilometer to 11,232 individuals per square kilometer (mean [SD] population density, 2579 [2485] individuals per square kilometer). Densely populated, moderately populated, and sparsely populated cities had a median population density of 4618, 1708, and 760 individuals per square kilometer, respectively. The data also were divided into 3 age groups. In the older population tier, the median percentage of individuals older than 64 years was 14.2%, the median percentage of individuals aged 18 to 64 years was 63.8%, and the median percentage of individuals aged 5 to 17 years was 14.9%. In the moderately aged population tier, the median percentage of individuals older than 64 years was 10.2%, the median percentage of individuals aged 18 to 64 years was 70.3%, and the median percentage of individuals aged 5 to 17 years was 13.6%. In the younger population tier, the median percentage of individuals older than 64 years was 12%, the median percentage of individuals aged 18 to 64 years was 66.8%, and the median percentage of individuals aged 5 to 17 years was 15%.

Practice and Physician Content—In the raw analysis (Figure), the most commonly listed types of content (>90% of websites) in both private practice and academic sites was address (range, 95% to 100%), telephone number (range, 97% to 100%), and dermatologist profiles (both 92%). The least commonly listed types of content in both cohorts was publicity (range, 20% to 23%). Private practices were more likely to list profiles of nondermatology professionals (73% vs 56%; P<.02), email (47% vs 17%; P<.0001), and social media (29% vs 8%; P<.0001) compared with academic institution websites. Although Facebook was the most-linked social media account for both groups, 75% of private practice sites included the link compared with 16% of academic institutions. Academic institutions were more likely to list fellowship availability (66% vs 1%; P<.0001). Accessing each website was significantly easier in the private practice cohort (99% vs 61%; P<.0001).

CT111006297_Fig.jpg

When controlling for population density, private practices were only more likely to list nondermatology professionals’ profiles in densely populated cities when compared with academic institutions (73% vs 41%; P<.01). Academic institutions continued to list fellowship availability more often than private practices regardless of population density. The same trend was observed for private practices with ease of site access and listing of social media.

When controlling for population age, similar trends were seen as when controlling for population density. However, private practices listing nondermatology professionals’ profiles was only more likely in the cities with a proportionately younger population when compared with academic institutions (74% vs 47%; P<.04). 

Patient and Treatment/Procedure—The most commonly listed content types on both private practice websites and academic institution websites were available treatments/procedures (range, 89% to 98%). The least commonly listed content included financing for elective procedures (range, 4% to 16%), consultation fees (range, 1% to 2%), FAQs (frequently asked questions)(range, 4% to 20%), and HIPAA (Health Insurance Portability and Accountability Act) policy (range, 12% to 22%). Private practices were more likely to list patient testimonials (52% vs 35%; P<.005), financing (16% vs 4%; P<.005), FAQs (20% vs 4%; P<.001), online appointments (77% vs 56%; P<.001), available treatments/procedures (98% vs 86%; P<.004), product advertisements (66% vs 16%; P<.0001), pictures of dermatology conditions (33% vs 13%; P<.001), and HIPAA policy (22% vs 12%; P<.04). Academic institutions were more likely to list research trials (65% vs 13%; P<.0001).

When controlling for population density, private practices were only more likely to list patient testimonials in densely populated (P=.035) and moderately populated cities (P=.019). The same trend was observed for online appointments in densely populated (P=.0023) and moderately populated cities (P=.037). Private practices continued to list product availability more often than academic institutions regardless of population density or population age. Academic institutions also continued to list research trials more often than private practices regardless of population density or population age. 

Comment

Our study uniquely analyzed the differences in website content between private practices and academic institutions in dermatology. Of the 140 academic institutions accredited by the Accreditation Council for Graduate Medical Education (ACGME), only 113 had patient-pertinent websites.

Access to Websites —There was a significant difference in many website content criteria between the 2 groups. Private practice sites were easier to access via a Google search when compared with academic sites, which likely is influenced by the Google search algorithm that ranks websites higher based on several criteria including but not limited to keyword use in the title tag, link popularity of the site, and historic ranking. ^12,13 Academic sites often were only accessible through portals found on their main institutional site or institution’s residency site.

Role of Social Media —Social media has been found to assist in educating patients on medical practices as well as selecting a physician. ^14,15 Our study found that private practice websites listed links to social media more often than their academic counterparts. Social media consumption is increasing, in part due to the COVID-19 pandemic, and it may be optimal for patients and practices alike to include links on their websites. ¹⁶ Facebook and Instagram were listed more often on private practice sites when compared with academic institution sites, which was similar to a recent study analyzing the websites of plastic surgery private practices (N = 310) in which 90% of private practices included some type of social media, with Instagram and Facebook being the most used. ⁸ Social networking accounts can act as convenient platforms for marketing, providing patient education, and generating referrals, which suggests that the prominence of their usage in private practice poses benefits in patient decision-making when seeking care. ^17-19 A study analyzing the impact of Facebook in medicine concluded that a Facebook page can serve as an effective vehicle for medical education, particularly in younger generations that favor technology-oriented teaching methods. ²⁰ A survey on trends in cosmetic facial procedures in plastic surgery found that the most influential online methods patients used for choosing their providers were social media platforms and practice websites. Front-page placement on Google also was commonly associated with the number of social media followers. ^21,22 A lack of social media prominence could hinder a website’s potential to reach patients.

Communication With Practices —Our study also found significant differences in other metrics related to a patient’s ability to directly communicate with a practice, such as physical addresses, telephone numbers, products available for direct purchase, and online appointment booking, all of which were listed more often on private practice websites compared with academic institution websites. Online appointment booking also was found more frequently on private practice websites. Although physical addresses and telephone numbers were listed significantly more often on private practice sites, this information was ubiquitous and easily accessible elsewhere. Academic institution websites listed research trials and fellowship training significantly more often than private practices. These differences imply a divergence in focus between private practices and academic institutions, likely because academic institutions are funded in large part from research grants, begetting a cycle of academic contribution. ²³ In contrast, private practices may not rely as heavily on academic revenue and may be more likely to prioritize other revenue streams such as product sales. ²⁴  

HIPAA Policy —Surprisingly, HIPAA policy rarely was listed on any private (22%) or academic site (12%). Conversely, in the plastic surgery study, HIPAA policy was listed much more often, with more than half of private practices with board-certified plastic surgeons accredited in the year 2015 including it on their website, ⁸ which may suggest that surgically oriented specialties, particularly cosmetic subspecialties, aim to more noticeably display their privacy policies for patient reassurance.

Study Limitations —There are several limitations of our study. First, it is common for a conglomerate company to own multiple private practices in different specialties. As with academic sites, private practice sites may be limited by the hosting platforms, which often are tedious to navigate. Also noteworthy is the emergence of designated social media management positions—both by practice employees and by third-party firms ²⁵ —but the impact of these positions in private practices and academic institutions has not been fully explored. Finally, inclusion criteria and standardized criteria definitions were chosen based on the precedent established by the authors of similar analyses in plastic surgery and radiology. ^5-8 Further investigation into the most valued aspects of care by patients within the context of the type of practice chosen would be valuable in refining inclusion criteria. Additionally, this study did not stratify the data collected based on factors such as gender, race, and geographical location; studies conducted on website traffic analysis patterns that focus on these aspects likely would further explain the significance of these findings. Differences in the length of time to the next available appointment between private practices and academic institutions also may help support our findings. Finally, there is a need for further investigation into the preferences of patients themselves garnered from website traffic alone.

Conclusion

Our study examined a diverse compilation of private practice and academic institution websites and uncovered numerous differences in content. As technology and health care continuously evolve, it is imperative that both private practices and academic institutions are actively adapting to optimize their online presence. In doing so, patients will be better equipped at accessing provider information, gaining familiarity with the practice, and understanding treatment options.  

Patients are finding it easier to use online resources to discover health care providers who fit their personalized needs. In the United States, approximately 70% of individuals use the internet to find health care information, and 80% are influenced by the information presented to them on health care websites.¹ Patients utilize the internet to better understand treatments offered by providers and their prices as well as how other patients have rated their experience. Providers in private practice also have noticed that many patients are referring themselves vs obtaining a referral from another provider.² As a result, it is critical for practice websites to have information that is of value to their patients, including the unique qualities and treatments offered. The purpose of this study was to analyze the differences between the content presented on dermatology private practice websites and academic institutional websites.

Methods

Websites Searched —All 140 academic dermatology programs, including both allopathic and osteopathic programs, were queried from the Association of American Medical Colleges (AAMC) database in March 2022. ³ First, the dermatology departmental websites for each program were analyzed to see if they contained information pertinent to patients. Any website that lacked this information or only had information relevant to the dermatology residency program was excluded from the study. After exclusion, a total of 113 websites were used in the academic website cohort. The private practices were found through an incognito Google search with the search term dermatologist and matched to be within 5 miles of each academic institution. The private practices that included at least one board-certified dermatologist and received the highest number of reviews on Google compared to other practices in the same region—a measure of online reputation—were selected to be in the private practice cohort (N = 113). Any duplicate practices, practices belonging to the same conglomerate company, or multispecialty clinics were excluded from the study. Board-certified dermatologists were confirmed using the Find a Dermatologist tool on the American Academy of Dermatology (AAD) website. ⁴

Website Assessments —Each website was assessed using 23 criteria divided into 4 categories: practice, physician(s), patient, and treatment/procedure (Table). Criteria for social media and publicity were further assessed. Criteria for social media included links on the website to a Facebook page, an Instagram account, a Twitter account, a Pinterest account, a LinkedIn account, a blog, a Yelp page, a YouTube channel, and/or any other social media. Criteria for publicity included links on the website to local television news, national news, newspapers, and/or magazines. ^5-8 Ease of site access was determined if the website was the first search result found on Google when searching for each website. Nondermatology professionals included listing of mid-level providers or researchers.

CT111006297_Table.jpg

Four individuals (V.S.J., A.C.B., M.E.O., and M.B.B.) independently assessed each of the websites using the established criteria. Each criterion was defined and discussed prior to data collection to maintain consistency. The criteria were determined as being present if the website clearly displayed, stated, explained, or linked to the relevant content. If the website did not directly contain the content, it was determined that the criteria were absent. One other individual (J.P.) independently cross-examined the data for consistency and evaluated for any discrepancies. ⁸

A raw analysis was done between each cohort. Another analysis was done that controlled for population density and the proportionate population age in each city ⁹ in which an academic institution/private practice was located. We proposed that more densely populated cities naturally may have more competition between practices, which may result in more optimized websites. ¹⁰ We also anticipated similar findings in cities with younger populations, as the younger demographic may be more likely to utilize and value online information when compared to older populations. ¹¹ The websites for each cohort were equally divided into 3 tiers of population density (not shown) and population age (not shown).

Statistical Analysis —Statistical analysis was completed using descriptive statistics, χ ² testing, and Fisher exact tests where appropriate with a predetermined level of significance of P < .05 in Microsoft Excel.

Results

Demographics —A total of 226 websites from both private practices and academic institutions were evaluated. Of them, only 108 private practices and 108 academic institutions listed practicing dermatologists on their site. Of 108 private practices, 76 (70.4%) had more than one practicing board-certified dermatologist. Of 108 academic institutions, all 108 (100%) institutions had more than one practicing board-certified dermatologist.

Of the dermatologists who practiced at academic institutions (n=2014) and private practices (n=817), 1157 (57.4%) and 419 (51.2%) were females, respectively. The population density of the cities with each of these practices/institutions ranged from 137 individuals per square kilometer to 11,232 individuals per square kilometer (mean [SD] population density, 2579 [2485] individuals per square kilometer). Densely populated, moderately populated, and sparsely populated cities had a median population density of 4618, 1708, and 760 individuals per square kilometer, respectively. The data also were divided into 3 age groups. In the older population tier, the median percentage of individuals older than 64 years was 14.2%, the median percentage of individuals aged 18 to 64 years was 63.8%, and the median percentage of individuals aged 5 to 17 years was 14.9%. In the moderately aged population tier, the median percentage of individuals older than 64 years was 10.2%, the median percentage of individuals aged 18 to 64 years was 70.3%, and the median percentage of individuals aged 5 to 17 years was 13.6%. In the younger population tier, the median percentage of individuals older than 64 years was 12%, the median percentage of individuals aged 18 to 64 years was 66.8%, and the median percentage of individuals aged 5 to 17 years was 15%.

Practice and Physician Content—In the raw analysis (Figure), the most commonly listed types of content (>90% of websites) in both private practice and academic sites was address (range, 95% to 100%), telephone number (range, 97% to 100%), and dermatologist profiles (both 92%). The least commonly listed types of content in both cohorts was publicity (range, 20% to 23%). Private practices were more likely to list profiles of nondermatology professionals (73% vs 56%; P<.02), email (47% vs 17%; P<.0001), and social media (29% vs 8%; P<.0001) compared with academic institution websites. Although Facebook was the most-linked social media account for both groups, 75% of private practice sites included the link compared with 16% of academic institutions. Academic institutions were more likely to list fellowship availability (66% vs 1%; P<.0001). Accessing each website was significantly easier in the private practice cohort (99% vs 61%; P<.0001).

CT111006297_Fig.jpg

When controlling for population density, private practices were only more likely to list nondermatology professionals’ profiles in densely populated cities when compared with academic institutions (73% vs 41%; P<.01). Academic institutions continued to list fellowship availability more often than private practices regardless of population density. The same trend was observed for private practices with ease of site access and listing of social media.

When controlling for population age, similar trends were seen as when controlling for population density. However, private practices listing nondermatology professionals’ profiles was only more likely in the cities with a proportionately younger population when compared with academic institutions (74% vs 47%; P<.04). 

Patient and Treatment/Procedure—The most commonly listed content types on both private practice websites and academic institution websites were available treatments/procedures (range, 89% to 98%). The least commonly listed content included financing for elective procedures (range, 4% to 16%), consultation fees (range, 1% to 2%), FAQs (frequently asked questions)(range, 4% to 20%), and HIPAA (Health Insurance Portability and Accountability Act) policy (range, 12% to 22%). Private practices were more likely to list patient testimonials (52% vs 35%; P<.005), financing (16% vs 4%; P<.005), FAQs (20% vs 4%; P<.001), online appointments (77% vs 56%; P<.001), available treatments/procedures (98% vs 86%; P<.004), product advertisements (66% vs 16%; P<.0001), pictures of dermatology conditions (33% vs 13%; P<.001), and HIPAA policy (22% vs 12%; P<.04). Academic institutions were more likely to list research trials (65% vs 13%; P<.0001).

When controlling for population density, private practices were only more likely to list patient testimonials in densely populated (P=.035) and moderately populated cities (P=.019). The same trend was observed for online appointments in densely populated (P=.0023) and moderately populated cities (P=.037). Private practices continued to list product availability more often than academic institutions regardless of population density or population age. Academic institutions also continued to list research trials more often than private practices regardless of population density or population age. 

Comment

Our study uniquely analyzed the differences in website content between private practices and academic institutions in dermatology. Of the 140 academic institutions accredited by the Accreditation Council for Graduate Medical Education (ACGME), only 113 had patient-pertinent websites.

Access to Websites —There was a significant difference in many website content criteria between the 2 groups. Private practice sites were easier to access via a Google search when compared with academic sites, which likely is influenced by the Google search algorithm that ranks websites higher based on several criteria including but not limited to keyword use in the title tag, link popularity of the site, and historic ranking. ^12,13 Academic sites often were only accessible through portals found on their main institutional site or institution’s residency site.

Role of Social Media —Social media has been found to assist in educating patients on medical practices as well as selecting a physician. ^14,15 Our study found that private practice websites listed links to social media more often than their academic counterparts. Social media consumption is increasing, in part due to the COVID-19 pandemic, and it may be optimal for patients and practices alike to include links on their websites. ¹⁶ Facebook and Instagram were listed more often on private practice sites when compared with academic institution sites, which was similar to a recent study analyzing the websites of plastic surgery private practices (N = 310) in which 90% of private practices included some type of social media, with Instagram and Facebook being the most used. ⁸ Social networking accounts can act as convenient platforms for marketing, providing patient education, and generating referrals, which suggests that the prominence of their usage in private practice poses benefits in patient decision-making when seeking care. ^17-19 A study analyzing the impact of Facebook in medicine concluded that a Facebook page can serve as an effective vehicle for medical education, particularly in younger generations that favor technology-oriented teaching methods. ²⁰ A survey on trends in cosmetic facial procedures in plastic surgery found that the most influential online methods patients used for choosing their providers were social media platforms and practice websites. Front-page placement on Google also was commonly associated with the number of social media followers. ^21,22 A lack of social media prominence could hinder a website’s potential to reach patients.

Communication With Practices —Our study also found significant differences in other metrics related to a patient’s ability to directly communicate with a practice, such as physical addresses, telephone numbers, products available for direct purchase, and online appointment booking, all of which were listed more often on private practice websites compared with academic institution websites. Online appointment booking also was found more frequently on private practice websites. Although physical addresses and telephone numbers were listed significantly more often on private practice sites, this information was ubiquitous and easily accessible elsewhere. Academic institution websites listed research trials and fellowship training significantly more often than private practices. These differences imply a divergence in focus between private practices and academic institutions, likely because academic institutions are funded in large part from research grants, begetting a cycle of academic contribution. ²³ In contrast, private practices may not rely as heavily on academic revenue and may be more likely to prioritize other revenue streams such as product sales. ²⁴  

HIPAA Policy —Surprisingly, HIPAA policy rarely was listed on any private (22%) or academic site (12%). Conversely, in the plastic surgery study, HIPAA policy was listed much more often, with more than half of private practices with board-certified plastic surgeons accredited in the year 2015 including it on their website, ⁸ which may suggest that surgically oriented specialties, particularly cosmetic subspecialties, aim to more noticeably display their privacy policies for patient reassurance.

Study Limitations —There are several limitations of our study. First, it is common for a conglomerate company to own multiple private practices in different specialties. As with academic sites, private practice sites may be limited by the hosting platforms, which often are tedious to navigate. Also noteworthy is the emergence of designated social media management positions—both by practice employees and by third-party firms ²⁵ —but the impact of these positions in private practices and academic institutions has not been fully explored. Finally, inclusion criteria and standardized criteria definitions were chosen based on the precedent established by the authors of similar analyses in plastic surgery and radiology. ^5-8 Further investigation into the most valued aspects of care by patients within the context of the type of practice chosen would be valuable in refining inclusion criteria. Additionally, this study did not stratify the data collected based on factors such as gender, race, and geographical location; studies conducted on website traffic analysis patterns that focus on these aspects likely would further explain the significance of these findings. Differences in the length of time to the next available appointment between private practices and academic institutions also may help support our findings. Finally, there is a need for further investigation into the preferences of patients themselves garnered from website traffic alone.

Conclusion

Our study examined a diverse compilation of private practice and academic institution websites and uncovered numerous differences in content. As technology and health care continuously evolve, it is imperative that both private practices and academic institutions are actively adapting to optimize their online presence. In doing so, patients will be better equipped at accessing provider information, gaining familiarity with the practice, and understanding treatment options.  

Patients are finding it easier to use online resources to discover health care providers who fit their personalized needs. In the United States, approximately 70% of individuals use the internet to find health care information, and 80% are influenced by the information presented to them on health care websites.¹ Patients utilize the internet to better understand treatments offered by providers and their prices as well as how other patients have rated their experience. Providers in private practice also have noticed that many patients are referring themselves vs obtaining a referral from another provider.² As a result, it is critical for practice websites to have information that is of value to their patients, including the unique qualities and treatments offered. The purpose of this study was to analyze the differences between the content presented on dermatology private practice websites and academic institutional websites.

Methods

Websites Searched —All 140 academic dermatology programs, including both allopathic and osteopathic programs, were queried from the Association of American Medical Colleges (AAMC) database in March 2022. ³ First, the dermatology departmental websites for each program were analyzed to see if they contained information pertinent to patients. Any website that lacked this information or only had information relevant to the dermatology residency program was excluded from the study. After exclusion, a total of 113 websites were used in the academic website cohort. The private practices were found through an incognito Google search with the search term dermatologist and matched to be within 5 miles of each academic institution. The private practices that included at least one board-certified dermatologist and received the highest number of reviews on Google compared to other practices in the same region—a measure of online reputation—were selected to be in the private practice cohort (N = 113). Any duplicate practices, practices belonging to the same conglomerate company, or multispecialty clinics were excluded from the study. Board-certified dermatologists were confirmed using the Find a Dermatologist tool on the American Academy of Dermatology (AAD) website. ⁴

Website Assessments —Each website was assessed using 23 criteria divided into 4 categories: practice, physician(s), patient, and treatment/procedure (Table). Criteria for social media and publicity were further assessed. Criteria for social media included links on the website to a Facebook page, an Instagram account, a Twitter account, a Pinterest account, a LinkedIn account, a blog, a Yelp page, a YouTube channel, and/or any other social media. Criteria for publicity included links on the website to local television news, national news, newspapers, and/or magazines. ^5-8 Ease of site access was determined if the website was the first search result found on Google when searching for each website. Nondermatology professionals included listing of mid-level providers or researchers.

CT111006297_Table.jpg

Four individuals (V.S.J., A.C.B., M.E.O., and M.B.B.) independently assessed each of the websites using the established criteria. Each criterion was defined and discussed prior to data collection to maintain consistency. The criteria were determined as being present if the website clearly displayed, stated, explained, or linked to the relevant content. If the website did not directly contain the content, it was determined that the criteria were absent. One other individual (J.P.) independently cross-examined the data for consistency and evaluated for any discrepancies. ⁸

A raw analysis was done between each cohort. Another analysis was done that controlled for population density and the proportionate population age in each city ⁹ in which an academic institution/private practice was located. We proposed that more densely populated cities naturally may have more competition between practices, which may result in more optimized websites. ¹⁰ We also anticipated similar findings in cities with younger populations, as the younger demographic may be more likely to utilize and value online information when compared to older populations. ¹¹ The websites for each cohort were equally divided into 3 tiers of population density (not shown) and population age (not shown).

Statistical Analysis —Statistical analysis was completed using descriptive statistics, χ ² testing, and Fisher exact tests where appropriate with a predetermined level of significance of P < .05 in Microsoft Excel.

Results

Demographics —A total of 226 websites from both private practices and academic institutions were evaluated. Of them, only 108 private practices and 108 academic institutions listed practicing dermatologists on their site. Of 108 private practices, 76 (70.4%) had more than one practicing board-certified dermatologist. Of 108 academic institutions, all 108 (100%) institutions had more than one practicing board-certified dermatologist.

Of the dermatologists who practiced at academic institutions (n=2014) and private practices (n=817), 1157 (57.4%) and 419 (51.2%) were females, respectively. The population density of the cities with each of these practices/institutions ranged from 137 individuals per square kilometer to 11,232 individuals per square kilometer (mean [SD] population density, 2579 [2485] individuals per square kilometer). Densely populated, moderately populated, and sparsely populated cities had a median population density of 4618, 1708, and 760 individuals per square kilometer, respectively. The data also were divided into 3 age groups. In the older population tier, the median percentage of individuals older than 64 years was 14.2%, the median percentage of individuals aged 18 to 64 years was 63.8%, and the median percentage of individuals aged 5 to 17 years was 14.9%. In the moderately aged population tier, the median percentage of individuals older than 64 years was 10.2%, the median percentage of individuals aged 18 to 64 years was 70.3%, and the median percentage of individuals aged 5 to 17 years was 13.6%. In the younger population tier, the median percentage of individuals older than 64 years was 12%, the median percentage of individuals aged 18 to 64 years was 66.8%, and the median percentage of individuals aged 5 to 17 years was 15%.

Practice and Physician Content—In the raw analysis (Figure), the most commonly listed types of content (>90% of websites) in both private practice and academic sites was address (range, 95% to 100%), telephone number (range, 97% to 100%), and dermatologist profiles (both 92%). The least commonly listed types of content in both cohorts was publicity (range, 20% to 23%). Private practices were more likely to list profiles of nondermatology professionals (73% vs 56%; P<.02), email (47% vs 17%; P<.0001), and social media (29% vs 8%; P<.0001) compared with academic institution websites. Although Facebook was the most-linked social media account for both groups, 75% of private practice sites included the link compared with 16% of academic institutions. Academic institutions were more likely to list fellowship availability (66% vs 1%; P<.0001). Accessing each website was significantly easier in the private practice cohort (99% vs 61%; P<.0001).

CT111006297_Fig.jpg

When controlling for population density, private practices were only more likely to list nondermatology professionals’ profiles in densely populated cities when compared with academic institutions (73% vs 41%; P<.01). Academic institutions continued to list fellowship availability more often than private practices regardless of population density. The same trend was observed for private practices with ease of site access and listing of social media.

When controlling for population age, similar trends were seen as when controlling for population density. However, private practices listing nondermatology professionals’ profiles was only more likely in the cities with a proportionately younger population when compared with academic institutions (74% vs 47%; P<.04). 

Patient and Treatment/Procedure—The most commonly listed content types on both private practice websites and academic institution websites were available treatments/procedures (range, 89% to 98%). The least commonly listed content included financing for elective procedures (range, 4% to 16%), consultation fees (range, 1% to 2%), FAQs (frequently asked questions)(range, 4% to 20%), and HIPAA (Health Insurance Portability and Accountability Act) policy (range, 12% to 22%). Private practices were more likely to list patient testimonials (52% vs 35%; P<.005), financing (16% vs 4%; P<.005), FAQs (20% vs 4%; P<.001), online appointments (77% vs 56%; P<.001), available treatments/procedures (98% vs 86%; P<.004), product advertisements (66% vs 16%; P<.0001), pictures of dermatology conditions (33% vs 13%; P<.001), and HIPAA policy (22% vs 12%; P<.04). Academic institutions were more likely to list research trials (65% vs 13%; P<.0001).

When controlling for population density, private practices were only more likely to list patient testimonials in densely populated (P=.035) and moderately populated cities (P=.019). The same trend was observed for online appointments in densely populated (P=.0023) and moderately populated cities (P=.037). Private practices continued to list product availability more often than academic institutions regardless of population density or population age. Academic institutions also continued to list research trials more often than private practices regardless of population density or population age. 

Comment

Our study uniquely analyzed the differences in website content between private practices and academic institutions in dermatology. Of the 140 academic institutions accredited by the Accreditation Council for Graduate Medical Education (ACGME), only 113 had patient-pertinent websites.

Access to Websites —There was a significant difference in many website content criteria between the 2 groups. Private practice sites were easier to access via a Google search when compared with academic sites, which likely is influenced by the Google search algorithm that ranks websites higher based on several criteria including but not limited to keyword use in the title tag, link popularity of the site, and historic ranking. ^12,13 Academic sites often were only accessible through portals found on their main institutional site or institution’s residency site.

Role of Social Media —Social media has been found to assist in educating patients on medical practices as well as selecting a physician. ^14,15 Our study found that private practice websites listed links to social media more often than their academic counterparts. Social media consumption is increasing, in part due to the COVID-19 pandemic, and it may be optimal for patients and practices alike to include links on their websites. ¹⁶ Facebook and Instagram were listed more often on private practice sites when compared with academic institution sites, which was similar to a recent study analyzing the websites of plastic surgery private practices (N = 310) in which 90% of private practices included some type of social media, with Instagram and Facebook being the most used. ⁸ Social networking accounts can act as convenient platforms for marketing, providing patient education, and generating referrals, which suggests that the prominence of their usage in private practice poses benefits in patient decision-making when seeking care. ^17-19 A study analyzing the impact of Facebook in medicine concluded that a Facebook page can serve as an effective vehicle for medical education, particularly in younger generations that favor technology-oriented teaching methods. ²⁰ A survey on trends in cosmetic facial procedures in plastic surgery found that the most influential online methods patients used for choosing their providers were social media platforms and practice websites. Front-page placement on Google also was commonly associated with the number of social media followers. ^21,22 A lack of social media prominence could hinder a website’s potential to reach patients.

Communication With Practices —Our study also found significant differences in other metrics related to a patient’s ability to directly communicate with a practice, such as physical addresses, telephone numbers, products available for direct purchase, and online appointment booking, all of which were listed more often on private practice websites compared with academic institution websites. Online appointment booking also was found more frequently on private practice websites. Although physical addresses and telephone numbers were listed significantly more often on private practice sites, this information was ubiquitous and easily accessible elsewhere. Academic institution websites listed research trials and fellowship training significantly more often than private practices. These differences imply a divergence in focus between private practices and academic institutions, likely because academic institutions are funded in large part from research grants, begetting a cycle of academic contribution. ²³ In contrast, private practices may not rely as heavily on academic revenue and may be more likely to prioritize other revenue streams such as product sales. ²⁴  

HIPAA Policy —Surprisingly, HIPAA policy rarely was listed on any private (22%) or academic site (12%). Conversely, in the plastic surgery study, HIPAA policy was listed much more often, with more than half of private practices with board-certified plastic surgeons accredited in the year 2015 including it on their website, ⁸ which may suggest that surgically oriented specialties, particularly cosmetic subspecialties, aim to more noticeably display their privacy policies for patient reassurance.

Study Limitations —There are several limitations of our study. First, it is common for a conglomerate company to own multiple private practices in different specialties. As with academic sites, private practice sites may be limited by the hosting platforms, which often are tedious to navigate. Also noteworthy is the emergence of designated social media management positions—both by practice employees and by third-party firms ²⁵ —but the impact of these positions in private practices and academic institutions has not been fully explored. Finally, inclusion criteria and standardized criteria definitions were chosen based on the precedent established by the authors of similar analyses in plastic surgery and radiology. ^5-8 Further investigation into the most valued aspects of care by patients within the context of the type of practice chosen would be valuable in refining inclusion criteria. Additionally, this study did not stratify the data collected based on factors such as gender, race, and geographical location; studies conducted on website traffic analysis patterns that focus on these aspects likely would further explain the significance of these findings. Differences in the length of time to the next available appointment between private practices and academic institutions also may help support our findings. Finally, there is a need for further investigation into the preferences of patients themselves garnered from website traffic alone.

Conclusion

Our study examined a diverse compilation of private practice and academic institution websites and uncovered numerous differences in content. As technology and health care continuously evolve, it is imperative that both private practices and academic institutions are actively adapting to optimize their online presence. In doing so, patients will be better equipped at accessing provider information, gaining familiarity with the practice, and understanding treatment options.  

Inpatient dermatology consultation services are becoming increasingly prevalent in hospital institutions.^1-3 Although often underutilized as a consulting service, dermatology-related admissions cost hundreds of millions of dollars for the health care system.^1,2 Misdiagnosis, prolonged hospital stays, and incorrect treatment are common results of lack of involvement by a skin expert.^1-3 The importance of consultative inpatient dermatology cannot be understated. Accreditation Council for Graduate Medical Education requirements for proficiency in dermatology residency include exposure to inpatient dermatology, and it is our duty as residents to aid our colleagues in the management and treatment of cutaneous disease.

Although exposure to inpatient dermatology varies across residency programs, nearly every dermatology resident is bound to perform a consultation and be involved in the care of a hospitalized patient. At our program at the University of Utah (Salt Lake City), we have robust inpatient exposure, and after numerous hours spent on the forefront of inpatient dermatology, I have accrued a list of specific tips and techniques that have aided me as a resident clinician.

Pre-Rounding More Thoroughly

When I started as a postgraduate year 2 (PGY-2) on the inpatient dermatology rotation, I found myself perplexed. I had learned how to round in internal medicine but was unaccustomed to the nuances of specialty rounds. My list included calciphylaxis, small vessel vasculitis, cellulitis, stasis dermatitis, toxic epidermal necrolysis, and atypical mycobacterial infection. The first few days of service were undeniably difficult due to the daily consultations, complexity of admitted patients, and need for efficiency. I sometimes overlooked important laboratory test results, medication changes, and interdisciplinary discussions that prolonged rounding. As dermatologists, we are responsible for the largest organ of the body, and it is important to approach patients in a comprehensive manner. Pre-rounding should include reviewing interdisciplinary notes, laboratory values/results, and medications, and performing a focused skin examination with a review of systems during the encounter. Importantly, most electronic medical record systems offer an automated rounding sheet. In Epic (Epic Systems Corporation), I would use the bone marrow transplant rounding sheet, which includes laboratory test results, vitals, and medications. After printing out the rounding sheet, I would note important updates for each patient. Although pre-rounding and chart review requires time and effort, it aided me in providing elevated patient care and becoming more efficient during rounds. Over time I have come to strongly appreciate the term dermatology hospitalist. Cutaneous manifestations of systemic disease require thoughtful consideration and workup.

New Patient Consultations: Must-Ask Questions

Holding the university inpatient pager can be stressful. At the University of Utah, we often carry 5 to 10 patients on our list and receive 3 to 4 new consultations a day, sometimes right before 5 pm. When receiving new consultations, it is important to obtain the whole story from the requesting provider. Some of the questions may seem obvious, but I am frequently reminded of the inefficiencies I encountered as a first-year dermatology resident. Remember to always be kind to your consulting colleagues. Dermatology is a difficult discipline, and describing rashes is no easy task. Here is my systematic approach to questions that should be asked of the requesting provider during each new patient consultation:

• What is the patient’s name, room number, and medical record number?
• Is this patient getting admitted or admitted currently?
• Is the rash the reason for admission? (This can greatly help with triaging the urgency of evaluation.)
• Is the rash painful?
• Is this patient ill?
• How would you describe the rash?

When evaluating new patients, it is crucial to remember the morphology camps. Formulating a differential diagnosis on a complex patient can be difficult; however, remembering the morphology camps of acneiform, dermal, eczematous, erythematous, subcutaneous, vasculitic, vasculopathic, and vesiculobullous lesions can be extremely helpful. Additionally, it is crucial to perform a thorough and complete skin examination on every patient. When emphasizing the importance of this, I often am reminded of a humbling moment early in my training. Our team was consulted on a patient with cellulitis and stasis dermatitis. It was a busy day, and my examination was quick and focused on the lower and upper extremities, chest, and back. The patient improved from a cutaneous standpoint and was discharged. At follow-up the next week, one of my attending providers biopsied an atypical macule on the retroauricular region, which was found to be consistent with a stage 1A melanoma. Even on the longest and most tiring hospital days, it is important to perform a full-body skin examination on each patient. You may end up saving a life.

An Organized Toolbox: What to Carry

Similar to our ophthalmology colleagues who are seen carrying around a suitcase in the hospital, I highly recommend some form of a toolbox or bag for performing inpatient biopsies (Table). Carrying around an organized bag, albeit bulky and unfashionable, has saved me numerous trips back to clinic for unexpected complications including fixing leaky vessels, closing stubborn ulcers, and coordinating sedated biopsies in the operating room.

CT111005011_e_Table.jpg

Final Thoughts

As I near the completion of my residency journey, I hope these tips will aid budding and current dermatology residents at excelling as dermatology hospitalists during inpatient rotations. Dermatologists can make a profound impact on a variety of patients, especially when treating hospitalized patients on the clinical forefront. Our role extends beyond the skin, as cutaneous manifestations of internal disease are not uncommon.

Inpatient dermatology consultation services are becoming increasingly prevalent in hospital institutions.^1-3 Although often underutilized as a consulting service, dermatology-related admissions cost hundreds of millions of dollars for the health care system.^1,2 Misdiagnosis, prolonged hospital stays, and incorrect treatment are common results of lack of involvement by a skin expert.^1-3 The importance of consultative inpatient dermatology cannot be understated. Accreditation Council for Graduate Medical Education requirements for proficiency in dermatology residency include exposure to inpatient dermatology, and it is our duty as residents to aid our colleagues in the management and treatment of cutaneous disease.

Although exposure to inpatient dermatology varies across residency programs, nearly every dermatology resident is bound to perform a consultation and be involved in the care of a hospitalized patient. At our program at the University of Utah (Salt Lake City), we have robust inpatient exposure, and after numerous hours spent on the forefront of inpatient dermatology, I have accrued a list of specific tips and techniques that have aided me as a resident clinician.

Pre-Rounding More Thoroughly

When I started as a postgraduate year 2 (PGY-2) on the inpatient dermatology rotation, I found myself perplexed. I had learned how to round in internal medicine but was unaccustomed to the nuances of specialty rounds. My list included calciphylaxis, small vessel vasculitis, cellulitis, stasis dermatitis, toxic epidermal necrolysis, and atypical mycobacterial infection. The first few days of service were undeniably difficult due to the daily consultations, complexity of admitted patients, and need for efficiency. I sometimes overlooked important laboratory test results, medication changes, and interdisciplinary discussions that prolonged rounding. As dermatologists, we are responsible for the largest organ of the body, and it is important to approach patients in a comprehensive manner. Pre-rounding should include reviewing interdisciplinary notes, laboratory values/results, and medications, and performing a focused skin examination with a review of systems during the encounter. Importantly, most electronic medical record systems offer an automated rounding sheet. In Epic (Epic Systems Corporation), I would use the bone marrow transplant rounding sheet, which includes laboratory test results, vitals, and medications. After printing out the rounding sheet, I would note important updates for each patient. Although pre-rounding and chart review requires time and effort, it aided me in providing elevated patient care and becoming more efficient during rounds. Over time I have come to strongly appreciate the term dermatology hospitalist. Cutaneous manifestations of systemic disease require thoughtful consideration and workup.

New Patient Consultations: Must-Ask Questions

Holding the university inpatient pager can be stressful. At the University of Utah, we often carry 5 to 10 patients on our list and receive 3 to 4 new consultations a day, sometimes right before 5 pm. When receiving new consultations, it is important to obtain the whole story from the requesting provider. Some of the questions may seem obvious, but I am frequently reminded of the inefficiencies I encountered as a first-year dermatology resident. Remember to always be kind to your consulting colleagues. Dermatology is a difficult discipline, and describing rashes is no easy task. Here is my systematic approach to questions that should be asked of the requesting provider during each new patient consultation:

• What is the patient’s name, room number, and medical record number?
• Is this patient getting admitted or admitted currently?
• Is the rash the reason for admission? (This can greatly help with triaging the urgency of evaluation.)
• Is the rash painful?
• Is this patient ill?
• How would you describe the rash?

When evaluating new patients, it is crucial to remember the morphology camps. Formulating a differential diagnosis on a complex patient can be difficult; however, remembering the morphology camps of acneiform, dermal, eczematous, erythematous, subcutaneous, vasculitic, vasculopathic, and vesiculobullous lesions can be extremely helpful. Additionally, it is crucial to perform a thorough and complete skin examination on every patient. When emphasizing the importance of this, I often am reminded of a humbling moment early in my training. Our team was consulted on a patient with cellulitis and stasis dermatitis. It was a busy day, and my examination was quick and focused on the lower and upper extremities, chest, and back. The patient improved from a cutaneous standpoint and was discharged. At follow-up the next week, one of my attending providers biopsied an atypical macule on the retroauricular region, which was found to be consistent with a stage 1A melanoma. Even on the longest and most tiring hospital days, it is important to perform a full-body skin examination on each patient. You may end up saving a life.

An Organized Toolbox: What to Carry

Similar to our ophthalmology colleagues who are seen carrying around a suitcase in the hospital, I highly recommend some form of a toolbox or bag for performing inpatient biopsies (Table). Carrying around an organized bag, albeit bulky and unfashionable, has saved me numerous trips back to clinic for unexpected complications including fixing leaky vessels, closing stubborn ulcers, and coordinating sedated biopsies in the operating room.

CT111005011_e_Table.jpg

Final Thoughts

As I near the completion of my residency journey, I hope these tips will aid budding and current dermatology residents at excelling as dermatology hospitalists during inpatient rotations. Dermatologists can make a profound impact on a variety of patients, especially when treating hospitalized patients on the clinical forefront. Our role extends beyond the skin, as cutaneous manifestations of internal disease are not uncommon.

Inpatient dermatology consultation services are becoming increasingly prevalent in hospital institutions.^1-3 Although often underutilized as a consulting service, dermatology-related admissions cost hundreds of millions of dollars for the health care system.^1,2 Misdiagnosis, prolonged hospital stays, and incorrect treatment are common results of lack of involvement by a skin expert.^1-3 The importance of consultative inpatient dermatology cannot be understated. Accreditation Council for Graduate Medical Education requirements for proficiency in dermatology residency include exposure to inpatient dermatology, and it is our duty as residents to aid our colleagues in the management and treatment of cutaneous disease.

Although exposure to inpatient dermatology varies across residency programs, nearly every dermatology resident is bound to perform a consultation and be involved in the care of a hospitalized patient. At our program at the University of Utah (Salt Lake City), we have robust inpatient exposure, and after numerous hours spent on the forefront of inpatient dermatology, I have accrued a list of specific tips and techniques that have aided me as a resident clinician.

Pre-Rounding More Thoroughly

When I started as a postgraduate year 2 (PGY-2) on the inpatient dermatology rotation, I found myself perplexed. I had learned how to round in internal medicine but was unaccustomed to the nuances of specialty rounds. My list included calciphylaxis, small vessel vasculitis, cellulitis, stasis dermatitis, toxic epidermal necrolysis, and atypical mycobacterial infection. The first few days of service were undeniably difficult due to the daily consultations, complexity of admitted patients, and need for efficiency. I sometimes overlooked important laboratory test results, medication changes, and interdisciplinary discussions that prolonged rounding. As dermatologists, we are responsible for the largest organ of the body, and it is important to approach patients in a comprehensive manner. Pre-rounding should include reviewing interdisciplinary notes, laboratory values/results, and medications, and performing a focused skin examination with a review of systems during the encounter. Importantly, most electronic medical record systems offer an automated rounding sheet. In Epic (Epic Systems Corporation), I would use the bone marrow transplant rounding sheet, which includes laboratory test results, vitals, and medications. After printing out the rounding sheet, I would note important updates for each patient. Although pre-rounding and chart review requires time and effort, it aided me in providing elevated patient care and becoming more efficient during rounds. Over time I have come to strongly appreciate the term dermatology hospitalist. Cutaneous manifestations of systemic disease require thoughtful consideration and workup.

New Patient Consultations: Must-Ask Questions

Holding the university inpatient pager can be stressful. At the University of Utah, we often carry 5 to 10 patients on our list and receive 3 to 4 new consultations a day, sometimes right before 5 pm. When receiving new consultations, it is important to obtain the whole story from the requesting provider. Some of the questions may seem obvious, but I am frequently reminded of the inefficiencies I encountered as a first-year dermatology resident. Remember to always be kind to your consulting colleagues. Dermatology is a difficult discipline, and describing rashes is no easy task. Here is my systematic approach to questions that should be asked of the requesting provider during each new patient consultation:

• What is the patient’s name, room number, and medical record number?
• Is this patient getting admitted or admitted currently?
• Is the rash the reason for admission? (This can greatly help with triaging the urgency of evaluation.)
• Is the rash painful?
• Is this patient ill?
• How would you describe the rash?

When evaluating new patients, it is crucial to remember the morphology camps. Formulating a differential diagnosis on a complex patient can be difficult; however, remembering the morphology camps of acneiform, dermal, eczematous, erythematous, subcutaneous, vasculitic, vasculopathic, and vesiculobullous lesions can be extremely helpful. Additionally, it is crucial to perform a thorough and complete skin examination on every patient. When emphasizing the importance of this, I often am reminded of a humbling moment early in my training. Our team was consulted on a patient with cellulitis and stasis dermatitis. It was a busy day, and my examination was quick and focused on the lower and upper extremities, chest, and back. The patient improved from a cutaneous standpoint and was discharged. At follow-up the next week, one of my attending providers biopsied an atypical macule on the retroauricular region, which was found to be consistent with a stage 1A melanoma. Even on the longest and most tiring hospital days, it is important to perform a full-body skin examination on each patient. You may end up saving a life.

An Organized Toolbox: What to Carry

Similar to our ophthalmology colleagues who are seen carrying around a suitcase in the hospital, I highly recommend some form of a toolbox or bag for performing inpatient biopsies (Table). Carrying around an organized bag, albeit bulky and unfashionable, has saved me numerous trips back to clinic for unexpected complications including fixing leaky vessels, closing stubborn ulcers, and coordinating sedated biopsies in the operating room.

CT111005011_e_Table.jpg

Final Thoughts

As I near the completion of my residency journey, I hope these tips will aid budding and current dermatology residents at excelling as dermatology hospitalists during inpatient rotations. Dermatologists can make a profound impact on a variety of patients, especially when treating hospitalized patients on the clinical forefront. Our role extends beyond the skin, as cutaneous manifestations of internal disease are not uncommon.

Sound moral principles are essential in the development of all physicians. Given how heavily each clinical encounter is laden with ethical implications, this is taught early in medical school. The medical student and resident physician must be able to make ethical and moral decisions on a consistent basis.

Speaking as a psychiatrist in training, there is an intimate relationship between psychiatry and moral questions.¹ Issues such as determining an individual’s ability to make decisions about their medical care, hospitalizing patients against their will, and involuntarily administering medication are an almost-daily occurrence.² Physicians, especially those who practice psychiatric medicine, must be ethically grounded to properly make these difficult but common decisions. It is also imperative that residents are given proper guidance in ethical practice in structured didactics and hands-on training.

However, many residents may be unfamiliar with ethics in research, more specifically ethical authorship. While some trainees might have participated in scholarly activities before residency, residency is the time to discover one’s interests, and residents are encouraged to engage in research. Unfortunately, many of the considerations surrounding ethical authorship are not emphasized, and questionable practices are common.³ In this article, I summarize the different faces of unethical authorship, and call for a greater emphasis on ethical authorship in medical residency training programs.

What drives unethical authorship practices

One of the main drivers for the increase in unethical practices is the need to publish to advance one’s academic career. The academic principle of “publish or perish” pressures many faculty researchers.³ The impact of this expectation plays a significant role in potentially unethical authorship practices, and also has increased the number of publications of mediocre quality or fraudulent data.⁴ This mindset has also seeped into the clinical world because promotions and financial bonuses are incentives for attending physicians to perform scholarly work. Due to these incentives and pressures, a senior academician might compel a junior researcher to include them as a coauthor on the junior researcher’s paper, even when the senior’s contributions to the paper might be limited.⁵

Most journals have specific criteria for authorship. The International Committee of Medical Journal Editors (ICMJE) has 4 core criteria for authorship: 1) substantial contributions to the conception or design of the work, or the acquisition, analysis, or interpretation of data for the work; 2) drafting the work or revising it critically for important intellectual content; 3) providing final approval of the version to be published, and 4) agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.^5,6 One survey found that in certain journals, approximately 15% of authors met full ICMJE authorship criteria, while one-half claimed there were substantial contributions but did not state anything more specific.⁷

There are several types of authorship abuse.⁵ Gift authorship is when authorship is awarded to a friend either out of respect or in hopes that friend will return the favor (quid pro quo). Ghost authorship occurs when a third party commissions an author to write or help write a paper (eg, when a pharmaceutical company hires writers to produce a paper about a medication they manufacture) or when legitimate authors are denied recognition on a paper. Honorary authorship occurs when authorship is granted with the hope that the reputation of the honorary author will increase the chances of the paper getting published and possibly boost citations.

While these forms of authorship abuse occur with unsettling frequency, they might not be common among physician trainees who do not engage in full-time research.⁵ Resident authors might be more likely to experience coercive authorship.

Continue to: Coercive authorship is when...

Coercive authorship is when an individual in a superior position (such as an attending physician) forces their name onto a paper of a junior individual (such as a resident). Kwok⁸ called this “The White Bull effect,” based on Greek mythology in which Zeus transformed himself into a white bull to seduce Europa. The White Bull represents the predatory nature of the senior individual who exploits ambiguous institutional research regulations to their benefit.⁸ They stretch out the ICMJE criteria, only superficially satisfying them to justify authorship. In this scenario, the attending physician with promotional incentives notices the work of a resident and demands authorship, given their role as the “supervising” physician (akin to general supervision of a research group). This is not justification for authorship per the ICMJE or any major medical journal criteria. However, a resident with limited research experience may agree to include the attending as a coauthor for a variety of reasons, including fear of a poor performance evaluation or professionalism complaints, or just to maintain a positive working relationship.

Serious implications

While there are countless reasons to be concerned about this behavior, the central issue is the attending physician’s role to train and/or mentor the resident. As previously stated, a physician—especially one practicing psychiatric medicine—must be of morally sound mind. A resident being taught unethical behaviors by their attending physician has dangerous implications. Academic dishonesty does not occur in vacuum. It is likely that dishonest and unethical behavior in research matters can cross over into the clinical arena. One study found that individuals who exhibit dishonest academic behavior are more likely to violate workplace policies.⁹ Also, these behaviors lead to increased moral disengagement in all areas.^10,11 Imagining a morally disengaged attending psychiatrist practicing medicine and training the next generation of psychiatrists is unsettling.

My hope is that residency programs discourage this detrimental conduct in their departments and support those trying to uphold integrity.

Sound moral principles are essential in the development of all physicians. Given how heavily each clinical encounter is laden with ethical implications, this is taught early in medical school. The medical student and resident physician must be able to make ethical and moral decisions on a consistent basis.

Speaking as a psychiatrist in training, there is an intimate relationship between psychiatry and moral questions.¹ Issues such as determining an individual’s ability to make decisions about their medical care, hospitalizing patients against their will, and involuntarily administering medication are an almost-daily occurrence.² Physicians, especially those who practice psychiatric medicine, must be ethically grounded to properly make these difficult but common decisions. It is also imperative that residents are given proper guidance in ethical practice in structured didactics and hands-on training.

However, many residents may be unfamiliar with ethics in research, more specifically ethical authorship. While some trainees might have participated in scholarly activities before residency, residency is the time to discover one’s interests, and residents are encouraged to engage in research. Unfortunately, many of the considerations surrounding ethical authorship are not emphasized, and questionable practices are common.³ In this article, I summarize the different faces of unethical authorship, and call for a greater emphasis on ethical authorship in medical residency training programs.

What drives unethical authorship practices

One of the main drivers for the increase in unethical practices is the need to publish to advance one’s academic career. The academic principle of “publish or perish” pressures many faculty researchers.³ The impact of this expectation plays a significant role in potentially unethical authorship practices, and also has increased the number of publications of mediocre quality or fraudulent data.⁴ This mindset has also seeped into the clinical world because promotions and financial bonuses are incentives for attending physicians to perform scholarly work. Due to these incentives and pressures, a senior academician might compel a junior researcher to include them as a coauthor on the junior researcher’s paper, even when the senior’s contributions to the paper might be limited.⁵

Most journals have specific criteria for authorship. The International Committee of Medical Journal Editors (ICMJE) has 4 core criteria for authorship: 1) substantial contributions to the conception or design of the work, or the acquisition, analysis, or interpretation of data for the work; 2) drafting the work or revising it critically for important intellectual content; 3) providing final approval of the version to be published, and 4) agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.^5,6 One survey found that in certain journals, approximately 15% of authors met full ICMJE authorship criteria, while one-half claimed there were substantial contributions but did not state anything more specific.⁷

There are several types of authorship abuse.⁵ Gift authorship is when authorship is awarded to a friend either out of respect or in hopes that friend will return the favor (quid pro quo). Ghost authorship occurs when a third party commissions an author to write or help write a paper (eg, when a pharmaceutical company hires writers to produce a paper about a medication they manufacture) or when legitimate authors are denied recognition on a paper. Honorary authorship occurs when authorship is granted with the hope that the reputation of the honorary author will increase the chances of the paper getting published and possibly boost citations.

While these forms of authorship abuse occur with unsettling frequency, they might not be common among physician trainees who do not engage in full-time research.⁵ Resident authors might be more likely to experience coercive authorship.

Continue to: Coercive authorship is when...

Coercive authorship is when an individual in a superior position (such as an attending physician) forces their name onto a paper of a junior individual (such as a resident). Kwok⁸ called this “The White Bull effect,” based on Greek mythology in which Zeus transformed himself into a white bull to seduce Europa. The White Bull represents the predatory nature of the senior individual who exploits ambiguous institutional research regulations to their benefit.⁸ They stretch out the ICMJE criteria, only superficially satisfying them to justify authorship. In this scenario, the attending physician with promotional incentives notices the work of a resident and demands authorship, given their role as the “supervising” physician (akin to general supervision of a research group). This is not justification for authorship per the ICMJE or any major medical journal criteria. However, a resident with limited research experience may agree to include the attending as a coauthor for a variety of reasons, including fear of a poor performance evaluation or professionalism complaints, or just to maintain a positive working relationship.

Serious implications

While there are countless reasons to be concerned about this behavior, the central issue is the attending physician’s role to train and/or mentor the resident. As previously stated, a physician—especially one practicing psychiatric medicine—must be of morally sound mind. A resident being taught unethical behaviors by their attending physician has dangerous implications. Academic dishonesty does not occur in vacuum. It is likely that dishonest and unethical behavior in research matters can cross over into the clinical arena. One study found that individuals who exhibit dishonest academic behavior are more likely to violate workplace policies.⁹ Also, these behaviors lead to increased moral disengagement in all areas.^10,11 Imagining a morally disengaged attending psychiatrist practicing medicine and training the next generation of psychiatrists is unsettling.

My hope is that residency programs discourage this detrimental conduct in their departments and support those trying to uphold integrity.

Sound moral principles are essential in the development of all physicians. Given how heavily each clinical encounter is laden with ethical implications, this is taught early in medical school. The medical student and resident physician must be able to make ethical and moral decisions on a consistent basis.

Speaking as a psychiatrist in training, there is an intimate relationship between psychiatry and moral questions.¹ Issues such as determining an individual’s ability to make decisions about their medical care, hospitalizing patients against their will, and involuntarily administering medication are an almost-daily occurrence.² Physicians, especially those who practice psychiatric medicine, must be ethically grounded to properly make these difficult but common decisions. It is also imperative that residents are given proper guidance in ethical practice in structured didactics and hands-on training.

However, many residents may be unfamiliar with ethics in research, more specifically ethical authorship. While some trainees might have participated in scholarly activities before residency, residency is the time to discover one’s interests, and residents are encouraged to engage in research. Unfortunately, many of the considerations surrounding ethical authorship are not emphasized, and questionable practices are common.³ In this article, I summarize the different faces of unethical authorship, and call for a greater emphasis on ethical authorship in medical residency training programs.

What drives unethical authorship practices

One of the main drivers for the increase in unethical practices is the need to publish to advance one’s academic career. The academic principle of “publish or perish” pressures many faculty researchers.³ The impact of this expectation plays a significant role in potentially unethical authorship practices, and also has increased the number of publications of mediocre quality or fraudulent data.⁴ This mindset has also seeped into the clinical world because promotions and financial bonuses are incentives for attending physicians to perform scholarly work. Due to these incentives and pressures, a senior academician might compel a junior researcher to include them as a coauthor on the junior researcher’s paper, even when the senior’s contributions to the paper might be limited.⁵

Most journals have specific criteria for authorship. The International Committee of Medical Journal Editors (ICMJE) has 4 core criteria for authorship: 1) substantial contributions to the conception or design of the work, or the acquisition, analysis, or interpretation of data for the work; 2) drafting the work or revising it critically for important intellectual content; 3) providing final approval of the version to be published, and 4) agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.^5,6 One survey found that in certain journals, approximately 15% of authors met full ICMJE authorship criteria, while one-half claimed there were substantial contributions but did not state anything more specific.⁷

There are several types of authorship abuse.⁵ Gift authorship is when authorship is awarded to a friend either out of respect or in hopes that friend will return the favor (quid pro quo). Ghost authorship occurs when a third party commissions an author to write or help write a paper (eg, when a pharmaceutical company hires writers to produce a paper about a medication they manufacture) or when legitimate authors are denied recognition on a paper. Honorary authorship occurs when authorship is granted with the hope that the reputation of the honorary author will increase the chances of the paper getting published and possibly boost citations.

While these forms of authorship abuse occur with unsettling frequency, they might not be common among physician trainees who do not engage in full-time research.⁵ Resident authors might be more likely to experience coercive authorship.

Continue to: Coercive authorship is when...

Coercive authorship is when an individual in a superior position (such as an attending physician) forces their name onto a paper of a junior individual (such as a resident). Kwok⁸ called this “The White Bull effect,” based on Greek mythology in which Zeus transformed himself into a white bull to seduce Europa. The White Bull represents the predatory nature of the senior individual who exploits ambiguous institutional research regulations to their benefit.⁸ They stretch out the ICMJE criteria, only superficially satisfying them to justify authorship. In this scenario, the attending physician with promotional incentives notices the work of a resident and demands authorship, given their role as the “supervising” physician (akin to general supervision of a research group). This is not justification for authorship per the ICMJE or any major medical journal criteria. However, a resident with limited research experience may agree to include the attending as a coauthor for a variety of reasons, including fear of a poor performance evaluation or professionalism complaints, or just to maintain a positive working relationship.

Serious implications

While there are countless reasons to be concerned about this behavior, the central issue is the attending physician’s role to train and/or mentor the resident. As previously stated, a physician—especially one practicing psychiatric medicine—must be of morally sound mind. A resident being taught unethical behaviors by their attending physician has dangerous implications. Academic dishonesty does not occur in vacuum. It is likely that dishonest and unethical behavior in research matters can cross over into the clinical arena. One study found that individuals who exhibit dishonest academic behavior are more likely to violate workplace policies.⁹ Also, these behaviors lead to increased moral disengagement in all areas.^10,11 Imagining a morally disengaged attending psychiatrist practicing medicine and training the next generation of psychiatrists is unsettling.

My hope is that residency programs discourage this detrimental conduct in their departments and support those trying to uphold integrity.

In a sea of blonde hair and blue eyes, my black hair and brown eyes stood out. At the time, I was a medical student and one of the few people of color rotating through the inpatient child psychiatric unit. While I was aware I looked “different,” I discovered that my young patients had an unbridled curiosity about such differences. Common questions I received included “Where are you from? Why are your eyes so small? Is it because you eat rice?” Their questions were never of malicious intent, but rather due to my patient’s unfamiliarity with the Asian-American community and with Black, Indigenous, and people of color (BIPOC) communities in general.

Therefore, it came as no surprise that my BIPOC patients could keenly detect similarities. I could see their eyes widen, a spark of recognition, surprise, or even perhaps relief, when they saw my dark hair or the color of my skin. For members of minority racial/ethnic groups in a predominantly White society, there is a special kinship with other underrepresented BIPOC individuals. We are a community; our shared experiences of discrimination and disadvantages bind us together.

Perhaps it was because of our similarities that my BIPOC patients felt comfortable sharing their most intimate secrets: struggling with social anxiety due to language barriers in school, feeling anxious about balancing their familial expectations vs being “American,” or wishing they were dead due to the color of their skin. It hurt to hear this from my patients. My BIPOC patients’ narratives shared a common theme of fear. Fear that others wouldn’t understand their experiences. Fear that no one would understand their pain. When I reflect upon my own experiences with racism, from microaggressions to outright threats, I am reminded of my own fears, loneliness, and pain. It is these experiences that fuel every BIPOC medical student, resident, and physician to provide culturally sensitive care to patients and promote greater mental health for the BIPOC community.

Why diversity matters

Diversity is important in health care. Our patients come from various backgrounds and cultural experiences. A 2019 survey recruited participants who self-identified with >1 race or as a member of an interracial family relationship, to evaluate their preferences in clinicians.¹ Through thematic evaluation of participants’ responses, researchers noted that participants expressed a preference for clinicians who identified as a person of color.¹ Participants desired clinicians who were culturally sensitive, who could connect and empathize with their experiences as people of color.¹ Ultimately, by having a diverse array of clinicians, health care systems ensure that medical professionals can make important connections with patients due to shared experiences.

I remember talking to a mother about her daughter’s suicide attempt. During our conversation, the mother began to shake her head. “She doesn’t have depression,” she exclaimed. “She needs to snap out of it.” As I listened to her, I was reminded of my own grandmother.

My grandmother struggled with depression throughout her life, yet she was adamant she was “fine.” For my grandmother, her insistence that she did not have depression was rooted in shame. In our community, depression was not viewed as a disease, but rather a moral failing. My patient’s mother shared a similar attitude towards depression, believing her daughter was struggling due to her lack of willpower.

As the only person of color on the treatment team, I understood the importance of helping others on the team to also understand the mother’s perspective—doing so changed the dynamics of the relationship between the team and the family. Rather than having an antagonistic view of the mother who seemed to be callous of her daughter’s needs, the team viewed her differently; she was now understood as a mother who was overwhelmed and lacked an understanding of the disease. This changed the treatment team’s focus. The first step was to educate the family about depression, before providing therapeutic and medication treatments.

To fully understand the patient, the physician must place the story in the correct context, recognizing how the intersectionality of race, sexuality, socioeconomic status, and culture impact mental health. I am now a resident, and as a physician, my primary goal is to be an advocate for patients. To improve patient care, we must continue to find ways to improve diversity in the field of psychiatry. One crucial way is for clinicians to share their stories and be vulnerable with our colleagues, as our patients are with us. Through sharing our personal narratives, we further honor and encourage greater diversity.

In a sea of blonde hair and blue eyes, my black hair and brown eyes stood out. At the time, I was a medical student and one of the few people of color rotating through the inpatient child psychiatric unit. While I was aware I looked “different,” I discovered that my young patients had an unbridled curiosity about such differences. Common questions I received included “Where are you from? Why are your eyes so small? Is it because you eat rice?” Their questions were never of malicious intent, but rather due to my patient’s unfamiliarity with the Asian-American community and with Black, Indigenous, and people of color (BIPOC) communities in general.

Therefore, it came as no surprise that my BIPOC patients could keenly detect similarities. I could see their eyes widen, a spark of recognition, surprise, or even perhaps relief, when they saw my dark hair or the color of my skin. For members of minority racial/ethnic groups in a predominantly White society, there is a special kinship with other underrepresented BIPOC individuals. We are a community; our shared experiences of discrimination and disadvantages bind us together.

Perhaps it was because of our similarities that my BIPOC patients felt comfortable sharing their most intimate secrets: struggling with social anxiety due to language barriers in school, feeling anxious about balancing their familial expectations vs being “American,” or wishing they were dead due to the color of their skin. It hurt to hear this from my patients. My BIPOC patients’ narratives shared a common theme of fear. Fear that others wouldn’t understand their experiences. Fear that no one would understand their pain. When I reflect upon my own experiences with racism, from microaggressions to outright threats, I am reminded of my own fears, loneliness, and pain. It is these experiences that fuel every BIPOC medical student, resident, and physician to provide culturally sensitive care to patients and promote greater mental health for the BIPOC community.

Why diversity matters

Diversity is important in health care. Our patients come from various backgrounds and cultural experiences. A 2019 survey recruited participants who self-identified with >1 race or as a member of an interracial family relationship, to evaluate their preferences in clinicians.¹ Through thematic evaluation of participants’ responses, researchers noted that participants expressed a preference for clinicians who identified as a person of color.¹ Participants desired clinicians who were culturally sensitive, who could connect and empathize with their experiences as people of color.¹ Ultimately, by having a diverse array of clinicians, health care systems ensure that medical professionals can make important connections with patients due to shared experiences.

I remember talking to a mother about her daughter’s suicide attempt. During our conversation, the mother began to shake her head. “She doesn’t have depression,” she exclaimed. “She needs to snap out of it.” As I listened to her, I was reminded of my own grandmother.

My grandmother struggled with depression throughout her life, yet she was adamant she was “fine.” For my grandmother, her insistence that she did not have depression was rooted in shame. In our community, depression was not viewed as a disease, but rather a moral failing. My patient’s mother shared a similar attitude towards depression, believing her daughter was struggling due to her lack of willpower.

As the only person of color on the treatment team, I understood the importance of helping others on the team to also understand the mother’s perspective—doing so changed the dynamics of the relationship between the team and the family. Rather than having an antagonistic view of the mother who seemed to be callous of her daughter’s needs, the team viewed her differently; she was now understood as a mother who was overwhelmed and lacked an understanding of the disease. This changed the treatment team’s focus. The first step was to educate the family about depression, before providing therapeutic and medication treatments.

To fully understand the patient, the physician must place the story in the correct context, recognizing how the intersectionality of race, sexuality, socioeconomic status, and culture impact mental health. I am now a resident, and as a physician, my primary goal is to be an advocate for patients. To improve patient care, we must continue to find ways to improve diversity in the field of psychiatry. One crucial way is for clinicians to share their stories and be vulnerable with our colleagues, as our patients are with us. Through sharing our personal narratives, we further honor and encourage greater diversity.

In a sea of blonde hair and blue eyes, my black hair and brown eyes stood out. At the time, I was a medical student and one of the few people of color rotating through the inpatient child psychiatric unit. While I was aware I looked “different,” I discovered that my young patients had an unbridled curiosity about such differences. Common questions I received included “Where are you from? Why are your eyes so small? Is it because you eat rice?” Their questions were never of malicious intent, but rather due to my patient’s unfamiliarity with the Asian-American community and with Black, Indigenous, and people of color (BIPOC) communities in general.

Therefore, it came as no surprise that my BIPOC patients could keenly detect similarities. I could see their eyes widen, a spark of recognition, surprise, or even perhaps relief, when they saw my dark hair or the color of my skin. For members of minority racial/ethnic groups in a predominantly White society, there is a special kinship with other underrepresented BIPOC individuals. We are a community; our shared experiences of discrimination and disadvantages bind us together.

Perhaps it was because of our similarities that my BIPOC patients felt comfortable sharing their most intimate secrets: struggling with social anxiety due to language barriers in school, feeling anxious about balancing their familial expectations vs being “American,” or wishing they were dead due to the color of their skin. It hurt to hear this from my patients. My BIPOC patients’ narratives shared a common theme of fear. Fear that others wouldn’t understand their experiences. Fear that no one would understand their pain. When I reflect upon my own experiences with racism, from microaggressions to outright threats, I am reminded of my own fears, loneliness, and pain. It is these experiences that fuel every BIPOC medical student, resident, and physician to provide culturally sensitive care to patients and promote greater mental health for the BIPOC community.

Why diversity matters

Diversity is important in health care. Our patients come from various backgrounds and cultural experiences. A 2019 survey recruited participants who self-identified with >1 race or as a member of an interracial family relationship, to evaluate their preferences in clinicians.¹ Through thematic evaluation of participants’ responses, researchers noted that participants expressed a preference for clinicians who identified as a person of color.¹ Participants desired clinicians who were culturally sensitive, who could connect and empathize with their experiences as people of color.¹ Ultimately, by having a diverse array of clinicians, health care systems ensure that medical professionals can make important connections with patients due to shared experiences.

I remember talking to a mother about her daughter’s suicide attempt. During our conversation, the mother began to shake her head. “She doesn’t have depression,” she exclaimed. “She needs to snap out of it.” As I listened to her, I was reminded of my own grandmother.

My grandmother struggled with depression throughout her life, yet she was adamant she was “fine.” For my grandmother, her insistence that she did not have depression was rooted in shame. In our community, depression was not viewed as a disease, but rather a moral failing. My patient’s mother shared a similar attitude towards depression, believing her daughter was struggling due to her lack of willpower.

As the only person of color on the treatment team, I understood the importance of helping others on the team to also understand the mother’s perspective—doing so changed the dynamics of the relationship between the team and the family. Rather than having an antagonistic view of the mother who seemed to be callous of her daughter’s needs, the team viewed her differently; she was now understood as a mother who was overwhelmed and lacked an understanding of the disease. This changed the treatment team’s focus. The first step was to educate the family about depression, before providing therapeutic and medication treatments.

To fully understand the patient, the physician must place the story in the correct context, recognizing how the intersectionality of race, sexuality, socioeconomic status, and culture impact mental health. I am now a resident, and as a physician, my primary goal is to be an advocate for patients. To improve patient care, we must continue to find ways to improve diversity in the field of psychiatry. One crucial way is for clinicians to share their stories and be vulnerable with our colleagues, as our patients are with us. Through sharing our personal narratives, we further honor and encourage greater diversity.