For Residents

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.

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.

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.

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.

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).

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.

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).

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.

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).

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.

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.

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.

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.

Diversity of health care professionals improves medical outcomes and quality of life in patients. ¹ There is a lack of diversity in dermatology, with only 4.2% of dermatologists identifying as Hispanic and 3% identifying as African American, ² possibly due to a lack of early exposure to dermatology among high school and undergraduate students, a low number of underrepresented students in medical school, a lack of formal mentorship programs geared to underrepresented students, and implicit biases. ^1-4 Furthermore, the field is competitive, with many more applicants than available positions. In 2022, there were 851 applicants competing for 492 residency positions in dermatology. ⁵ Thus, it is important to educate young students about dermatology and understand root causes as to why the number of u nderrepresented in medicine (UiM) dermatologists remains stagnant.

According to Pritchett et al,⁴ it is crucial for dermatologists to interact with high school and college students to foster an early interest in dermatology. Many racial minority students do not progress from high school to college and then from college to medical school, which leaves a substantially reduced number of eligible UiM applicants who can progress into dermatology.⁶ Increasing the amount of UiM students going to medical school requires early mediation. Collaborating with pre-existing premedical school organizations through presentations and workshops is another way to promote an early interest in dermatology.⁴ Special consideration should be given to students who are UiM.

Among the general medical school curriculum, requirements for exposure to dermatology are not high. In one study, the median number of clinical and preclinical hours required was 10. Furthermore, 20% of 33 medical schools did not require preclinical dermatology hours (hours done before medical school rotations begin and in an academic setting), 36% required no clinical hours (rotational hours), 8% required no dermatology hours whatsoever, and only 10% required clinical dermatology rotation.³ Based on these findings, it is clear that dermatology is not well incorporated into medical school curricula. Furthermore, curricula have historically neglected to display adequate representation of skin of color.⁷ As a result, medical students generally have limited exposure to dermatology³ and are exposed even less to presentations of dermatologic issues in historically marginalized populations.⁷

Given the paucity of research on UiM students’ perceptions of dermatology prior to medical school, our cross-sectional survey study sought to evaluate the level of interest in dermatology of UiM premedical undergraduates. This survey specifically evaluated exposure to dermatology, preconceived notions about the field, and mentorship opportunities. By understanding these factors, dermatologists and dermatology residency programs can use this information to create mentorship opportunities and better adjust existing programs to meet students’ needs.

Methods

A 19-question multiple-choice survey was administered electronically (SurveyMonkey) in May 2020 to premedical students at Howard University (Washington, DC). One screening question was used: “What is your major?” Those who considered themselves a science major and/or with premedical interest were allowed to complete the survey. All students surveyed were members of the Health Professions Society at Howard University. Students who were interested in pursuing medical school were invited to respond. Approval for this study was obtained from the Howard University institutional review board (FWA00000891).

The survey was divided into 3 sections: Demographics, Exposure to Medicine and Dermatology, and Perceptions of Dermatology. The Demographics section addressed gender, age, and race/ethnicity. The Exposure to Medicine and Dermatology section addressed interest in attending medical school, shadowing experience, exposure to dermatology, and mentoring. The Perceptions of Dermatology section addressed preconceived notions about the field (eg, “dermatology is interesting and exciting”).

Statistical Analysis—The data represented are percentages based on the number of respondents who answered each question. Answers in response to “Please enter any comments” were organized into themes, and the number of respondents who discussed each theme was quantified into a table.

A total of 271 survey invitations were sent to premedical students at Howard University. Students were informed of the study protocol and asked to consent before proceeding to have their responses anonymously collected. Based on the screening question, 152 participants qualified for the survey, and 152 participants completed it (response rate, 56%; completion rate, 100%). Participants were asked to complete the survey only once.

Demographics—Eighty-four percent of respondents identified as science majors, and the remaining 16% identified as nonscience premedical. Ninety-four percent of participants identified as Black or African American; 3% as Asian or Asian American; and the remaining 3% as Other. Most respondents were female (82%), 16% were male, and 2% were either nonbinary or preferred not to answer. Ninety-nine percent were aged 18 to 24 years, and 1% were aged 25 to 34 years (Table 1).

Exposure to Medicine and Dermatology—Ninety-three percent of participants planned on attending medical school, and most students developed an interest in medicine from an early age. Ninety-six percent cited that they became interested in medicine prior to beginning their undergraduate education, and 4% developed an interest as freshmen or sophomores. When asked what led to their interest in medicine, family influence had the single greatest impact on students’ decision to pursue medicine (33%). Classes/school were the second most influential factor (24%), followed by volunteering (15%), shadowing (13%), other (7%), and peer influence (3%)(Figure 1).

Many (56%) premedical students surveyed had shadowing experience to varying degrees. Approximately 18% had fewer than 8 hours of shadowing experience, 24% had 8 to 40 hours, and 14% had more than 40 hours. However, many (43%) premedical students had no shadowing experience (Figure 2). Similarly, 30% of premedical students responded to having a physician as a mentor.

Regarding exposure to dermatology, 42% of premedical students had none. However, 58% of students had exposure to dermatology by being a patient themselves, 40% through seeing a dermatologist with a family member, 21% through seeing a dermatologist on television or social media, 5% through shadowing or volunteering, 3% through mentorship, and 1% through dermatology research (Figure 3).

Of students who said they were interested in dermatology (32%), 16% developed their interest before undergraduate education, while 9% developed interest in their freshman or sophomore year and 7% in their junior or senior year of undergraduate education. Three percent of respondents indicated that they had a dermatology mentorship.

Perceptions of Dermatology—To further evaluate the level of interest that UiM premedical students have in the field of dermatology, students were asked how much they agree or disagree on whether the field of dermatology is interesting. Sixty-three percent of the students agreed that the field of dermatology is interesting, 34% remained uncertain, and 3% disagreed. Additionally, students were asked whether they would consider dermatology as a career; 54% of respondents would consider dermatology as a career, 30% remained uncertain, and 16% would not consider dermatology as a career choice.

Nearly all (95%) students agreed that dermatologists do valuable work that goes beyond the scope of cosmetic procedures such as neuromodulators, fillers, chemical peels, and lasers. Some students also noted they had personal experiences interacting with a dermatologist. For example, one student described visiting the dermatologist many times to get a treatment regimen for their eczema.

Overall themes from the survey are depicted in Table 2. Major themes found in the comments included the desire for more dermatology-related opportunities, mentorship, exposure, connections, and a discussion of disparities faced by Black patients and students within dermatology. Students also expressed an interest in dermatology and the desire to learn more about the specialty.

Comment

Interest in Dermatology—In this cross-sectional survey study of 152 UiM undergraduate students, it was found that many students were interested in dermatology as a career, and more than 70% would be interested in attending events that increased exposure to the field of dermatology. Of the students who had any exposure to dermatology, less than 5% had shadowed an actual dermatologist. The survey showed that there is great potential interest in exposing UiM undergraduate students to the field of dermatology. We found that UiM students are interested in learning more about dermatology, with 80% indicating that they would be willing to participate in dermatology-focused events if they were available. Overall, students mentioned a lack of opportunities, mentorship, exposure, and connections in dermatology despite their interest in the field.

Racial Disparities in Dermatology—Additionally, students discussed disparities they encountered with dermatology due to a lack of patient-provider race concordance and the perceived difference in care when encountering a race-concordant dermatologist. One student noted that they went to multiple White dermatologists for their eczema, and “it wasn’t until I was evaluated by a Black dermatologist (diagnosed with eczema as well) [that I was] prescribed . . . the perfect medication.” Another student noted how a Black dermatologist sparked their interest in getting to know more about the field and remarked that they “think it is an important field that lacks representation for Black people.” This research stresses the need for more dermatology mentorship among UiM undergraduates.

Family Influence on Career Selection—The majority of UiM students in our study became interested in medicine because of family, which is consistent with other studies. In a cross-sectional survey of 300 Pakistani students (150 medical and 150 nonmedical), 87% of students stated that their family had an influence on their career selection.⁸ In another study of 15 junior doctors in Sierra Leone, the most common reasons for pursuing medicine were the desire to help and familial and peer influence.⁹ This again showcases how family can have a positive impact on career selection for medical professionals and highlights the need for early intervention.

Shadowing—One way in which student exposure to dermatology can be effectively increased is by shadowing. In a study evaluating a 30-week shadowing program at the Pediatric Continuity Clinic in Los Angeles, California, a greater proportion of premedical students believed they had a good understanding of the job of a resident physician after the program’s completion compared to before starting the program (an increase from 78% to 100%).¹⁰ The proportion of students reporting a good understanding of the patient-physician relationship after completing the program also increased from 33% to 78%. Furthermore, 72% of the residents stated that having the undergraduates in the clinic was a positive experience.¹⁰ Thus, increasing shadowing opportunities is one extremely effective way to increase student knowledge and awareness of and exposure to dermatology.

Dermatology Mentors—Although 32% of students were interested in dermatology, 3% of students had mentorship in dermatology. In prior studies, it has been shown that mentorship is of great importance in student success and interest in pursuing a specialty. A report from the Association of American Medical Colleges 2019 Medical School Graduation Questionnaire found that the third most influential factor (52.1%) in specialty selection was role model influence.¹¹ In fact, having a role model is consistently one of the top 3 influences on student specialty choice and interest in the last 5 years of survey research. Some studies also have shown mentorship as a positive influence in specialty interest at the undergraduate and graduate levels. A study on an undergraduate student interest group noted that surgeon mentorship and exposure were positive factors to students’ interests in surgery.¹² In fact, the Association of American Medical Colleges noted that some surgical specialties, such as orthopedic surgery, had 45% of respondents who were interested in the specialty before medical school pursue their initial preference in medical school.¹³ Another survey corroborated these findings; more orthopedic-bound students compared with other specialties indicated they were more likely to pursue their field because of experiences prior to medical school.¹⁴

One of the reasons students might not have been exposed to as many opportunities for mentorship in dermatology is because the specialty is one of the smaller fields in medicine and tends to be concentrated in more well-resourced metropolitan areas.¹⁵ Dermatologists make up only 1.3% of the physician workforce.¹⁶ Because there might not be as much exposure to the field, students might also explore their interests in dermatology through other fields, such as through shadowing and observing primary care physicians who often treat patients with dermatologic issues. Skin diseases are a common reason for primary care visits, and one study suggested dermatologic diseases can make up approximately 8.4% of visits in primary care.¹⁷

Moreover, only 1% of medical schools require an elective in dermatology.¹⁸ With exposure being a crucial component to pursuing the specialty, it also is important to pursue formal mentorship within the specialty itself. One study noted that formal mentorship in dermatology was important for most (67%) respondents when considering the specialty; however, 39% of respondents mentioned receiving mentorship in the past. In fact, dermatology was one of the top 3 specialties for which respondents agreed that formal mentorship was important.¹⁹

Mentorship also has been shown to provide students with a variety of opportunities to develop personally and professionally. Some of these opportunities include increased confidence in their personal and professional success, increased desire to pursue a career in a field of interest, networking opportunities, career coaching, and support and research guidance.²⁰ A research study among medical students at Albert Einstein College of Medicine in New York, New York, found that US Medical Licensing Examination Step 1 scores, clinical grades, and the chance of not matching were important factors preventing them from applying to dermatology.²¹

Factors in Dermatology Residency Selection—A survey was conducted wherein 95 of 114 dermatology program directors expressed that among the top 5 criteria for dermatology resident selection were Step 1 scores and clinical grades, supporting the notion that academic factors were given a great emphasis during residency selection.²² Furthermore, among underrepresented minority medical students, a lack of diversity, the belief that minority students are seen negatively by residencies, socioeconomic factors, and not having mentors were major reasons for being dissuaded from applying to dermatology.²¹ These results showcase the heightened importance of mentors for underrepresented minority medical students in particular.

In graduate medical education, resources such as wikis, social networking sites, and blogs provide media through which trainees can communicate, exchange ideas, and enhance their medical knowledge.^23,24 A survey of 9606 osteopathic medical students showed that 35% of 992 respondents had used social media to learn more about residencies, and 10% believed that social media had influenced their choice of residency.²⁵ Given the impact social media has on recruitment, it also can be employed in a similar manner by dermatologists and dermatology residency programs to attract younger students to the field.

Access to More Opportunities to Learn About Dermatology—Besides shadowing and mentorship, other avenues of exposure to dermatology are possible and should be considered. In our study, 80% of students agreed that they would attend an event that increases exposure to dermatology if held by the premedical group, which suggests that students are eager to learn more about the field and want access to more opportunities, which could include learning procedures such as suturing or how to use a dermatoscope, attending guest speaker events, or participating in Learn2Derm volunteer events.

Learn2Derm was a skin cancer prevention fair first organized by medical students at George Washington University in Washington, DC. Students and residents sought to deliver sunscreens to underserved areas in Washington, DC, as well as teach residents about the importance of skin health. Participating in such events could be an excellent opportunity for all students to gain exposure to important topics in dermatology.²⁶

General Opinions of Dermatology—General opinions about dermatology and medicine were collected from the students through the optional “Additional Comments” section. Major themes found in the comments included the desire for more opportunities, mentorship, exposure, connections, and a discussion of disparities faced by Black patients/students within dermatology. Students also expressed an interest in dermatology and the desire to learn more about the specialty. From these themes, it can be gleaned that students are open to and eager for more opportunities to gain exposure and connections, and increasing the number of minority dermatologists is of importance.

Limitations—An important limitation of this study was the potential for selection bias, as the sample was chosen from a population at one university, which is not representative of the general population. Further, we only sampled students who were premedical and likely from a UiM racial group due to the demographics of the student population at the university, but given that the goal of the survey was to understand exposure to dermatology in underrepresented groups, we believe it was the appropriate population to target. Additionally, results were not compared with other more represented racial groups to see if these findings were unique to UiM undergraduate students.

Conclusion

Among premedical students, dermatology is an area of great interest with minimal opportunities available for exposure and learning because it is a smaller specialty with fewer experiences available for shadowing and mentorship. Although most UiM premedical students who were surveyed were exposed to the field through either the media or being a dermatology patient, fewer were exposed to the field through clinical experiences (such as shadowing) or mentorship. Most respondents found dermatology to be interesting and have considered pursuing it as a career. In particular, race-concordant mentoring in dermatologic care was valued by many students in garnering their interest in the field.

Most UiM students wanted more exposure to dermatology-related opportunities as well as mentorship and connections. Increasing shadowing, research, pipeline programs, and general events geared to dermatology are some modalities that could help improve exposure to dermatology for UiM students, especially for those interested in pursuing the field. This increased exposure can help positively influence more UiM students to pursue dermatology and help close the diversity gap in the field. Additionally, many were interested in attending potential dermatology informational events.

Given the fact that dermatology is a small field and mentorship may be hard to access, increasing informational events may be a more reasonable approach to inspiring and supporting interest. These events could include learning how to use certain tools and techniques, guest speaker events, or participating in educational volunteer efforts such as Learn2Derm.²⁶

Future research should focus on identifying beneficial factors of UiM premedical students who retain an interest in dermatology throughout their careers and actually apply to dermatology programs and become dermatologists. Those who do not apply to the specialty can be identified to understand potential dissuading factors and obstacles. Ultimately, more research and development of exposure opportunities, including mentorship programs and informational events, can be used to close the gap and improve diversity and health outcomes in dermatology.

Diversity of health care professionals improves medical outcomes and quality of life in patients. ¹ There is a lack of diversity in dermatology, with only 4.2% of dermatologists identifying as Hispanic and 3% identifying as African American, ² possibly due to a lack of early exposure to dermatology among high school and undergraduate students, a low number of underrepresented students in medical school, a lack of formal mentorship programs geared to underrepresented students, and implicit biases. ^1-4 Furthermore, the field is competitive, with many more applicants than available positions. In 2022, there were 851 applicants competing for 492 residency positions in dermatology. ⁵ Thus, it is important to educate young students about dermatology and understand root causes as to why the number of u nderrepresented in medicine (UiM) dermatologists remains stagnant.

According to Pritchett et al,⁴ it is crucial for dermatologists to interact with high school and college students to foster an early interest in dermatology. Many racial minority students do not progress from high school to college and then from college to medical school, which leaves a substantially reduced number of eligible UiM applicants who can progress into dermatology.⁶ Increasing the amount of UiM students going to medical school requires early mediation. Collaborating with pre-existing premedical school organizations through presentations and workshops is another way to promote an early interest in dermatology.⁴ Special consideration should be given to students who are UiM.

Among the general medical school curriculum, requirements for exposure to dermatology are not high. In one study, the median number of clinical and preclinical hours required was 10. Furthermore, 20% of 33 medical schools did not require preclinical dermatology hours (hours done before medical school rotations begin and in an academic setting), 36% required no clinical hours (rotational hours), 8% required no dermatology hours whatsoever, and only 10% required clinical dermatology rotation.³ Based on these findings, it is clear that dermatology is not well incorporated into medical school curricula. Furthermore, curricula have historically neglected to display adequate representation of skin of color.⁷ As a result, medical students generally have limited exposure to dermatology³ and are exposed even less to presentations of dermatologic issues in historically marginalized populations.⁷

Given the paucity of research on UiM students’ perceptions of dermatology prior to medical school, our cross-sectional survey study sought to evaluate the level of interest in dermatology of UiM premedical undergraduates. This survey specifically evaluated exposure to dermatology, preconceived notions about the field, and mentorship opportunities. By understanding these factors, dermatologists and dermatology residency programs can use this information to create mentorship opportunities and better adjust existing programs to meet students’ needs.

Methods

A 19-question multiple-choice survey was administered electronically (SurveyMonkey) in May 2020 to premedical students at Howard University (Washington, DC). One screening question was used: “What is your major?” Those who considered themselves a science major and/or with premedical interest were allowed to complete the survey. All students surveyed were members of the Health Professions Society at Howard University. Students who were interested in pursuing medical school were invited to respond. Approval for this study was obtained from the Howard University institutional review board (FWA00000891).

The survey was divided into 3 sections: Demographics, Exposure to Medicine and Dermatology, and Perceptions of Dermatology. The Demographics section addressed gender, age, and race/ethnicity. The Exposure to Medicine and Dermatology section addressed interest in attending medical school, shadowing experience, exposure to dermatology, and mentoring. The Perceptions of Dermatology section addressed preconceived notions about the field (eg, “dermatology is interesting and exciting”).

Statistical Analysis—The data represented are percentages based on the number of respondents who answered each question. Answers in response to “Please enter any comments” were organized into themes, and the number of respondents who discussed each theme was quantified into a table.

A total of 271 survey invitations were sent to premedical students at Howard University. Students were informed of the study protocol and asked to consent before proceeding to have their responses anonymously collected. Based on the screening question, 152 participants qualified for the survey, and 152 participants completed it (response rate, 56%; completion rate, 100%). Participants were asked to complete the survey only once.

Demographics—Eighty-four percent of respondents identified as science majors, and the remaining 16% identified as nonscience premedical. Ninety-four percent of participants identified as Black or African American; 3% as Asian or Asian American; and the remaining 3% as Other. Most respondents were female (82%), 16% were male, and 2% were either nonbinary or preferred not to answer. Ninety-nine percent were aged 18 to 24 years, and 1% were aged 25 to 34 years (Table 1).

Exposure to Medicine and Dermatology—Ninety-three percent of participants planned on attending medical school, and most students developed an interest in medicine from an early age. Ninety-six percent cited that they became interested in medicine prior to beginning their undergraduate education, and 4% developed an interest as freshmen or sophomores. When asked what led to their interest in medicine, family influence had the single greatest impact on students’ decision to pursue medicine (33%). Classes/school were the second most influential factor (24%), followed by volunteering (15%), shadowing (13%), other (7%), and peer influence (3%)(Figure 1).

Many (56%) premedical students surveyed had shadowing experience to varying degrees. Approximately 18% had fewer than 8 hours of shadowing experience, 24% had 8 to 40 hours, and 14% had more than 40 hours. However, many (43%) premedical students had no shadowing experience (Figure 2). Similarly, 30% of premedical students responded to having a physician as a mentor.

Regarding exposure to dermatology, 42% of premedical students had none. However, 58% of students had exposure to dermatology by being a patient themselves, 40% through seeing a dermatologist with a family member, 21% through seeing a dermatologist on television or social media, 5% through shadowing or volunteering, 3% through mentorship, and 1% through dermatology research (Figure 3).

Of students who said they were interested in dermatology (32%), 16% developed their interest before undergraduate education, while 9% developed interest in their freshman or sophomore year and 7% in their junior or senior year of undergraduate education. Three percent of respondents indicated that they had a dermatology mentorship.

Perceptions of Dermatology—To further evaluate the level of interest that UiM premedical students have in the field of dermatology, students were asked how much they agree or disagree on whether the field of dermatology is interesting. Sixty-three percent of the students agreed that the field of dermatology is interesting, 34% remained uncertain, and 3% disagreed. Additionally, students were asked whether they would consider dermatology as a career; 54% of respondents would consider dermatology as a career, 30% remained uncertain, and 16% would not consider dermatology as a career choice.

Nearly all (95%) students agreed that dermatologists do valuable work that goes beyond the scope of cosmetic procedures such as neuromodulators, fillers, chemical peels, and lasers. Some students also noted they had personal experiences interacting with a dermatologist. For example, one student described visiting the dermatologist many times to get a treatment regimen for their eczema.

Overall themes from the survey are depicted in Table 2. Major themes found in the comments included the desire for more dermatology-related opportunities, mentorship, exposure, connections, and a discussion of disparities faced by Black patients and students within dermatology. Students also expressed an interest in dermatology and the desire to learn more about the specialty.

Comment

Interest in Dermatology—In this cross-sectional survey study of 152 UiM undergraduate students, it was found that many students were interested in dermatology as a career, and more than 70% would be interested in attending events that increased exposure to the field of dermatology. Of the students who had any exposure to dermatology, less than 5% had shadowed an actual dermatologist. The survey showed that there is great potential interest in exposing UiM undergraduate students to the field of dermatology. We found that UiM students are interested in learning more about dermatology, with 80% indicating that they would be willing to participate in dermatology-focused events if they were available. Overall, students mentioned a lack of opportunities, mentorship, exposure, and connections in dermatology despite their interest in the field.

Racial Disparities in Dermatology—Additionally, students discussed disparities they encountered with dermatology due to a lack of patient-provider race concordance and the perceived difference in care when encountering a race-concordant dermatologist. One student noted that they went to multiple White dermatologists for their eczema, and “it wasn’t until I was evaluated by a Black dermatologist (diagnosed with eczema as well) [that I was] prescribed . . . the perfect medication.” Another student noted how a Black dermatologist sparked their interest in getting to know more about the field and remarked that they “think it is an important field that lacks representation for Black people.” This research stresses the need for more dermatology mentorship among UiM undergraduates.

Family Influence on Career Selection—The majority of UiM students in our study became interested in medicine because of family, which is consistent with other studies. In a cross-sectional survey of 300 Pakistani students (150 medical and 150 nonmedical), 87% of students stated that their family had an influence on their career selection.⁸ In another study of 15 junior doctors in Sierra Leone, the most common reasons for pursuing medicine were the desire to help and familial and peer influence.⁹ This again showcases how family can have a positive impact on career selection for medical professionals and highlights the need for early intervention.

Shadowing—One way in which student exposure to dermatology can be effectively increased is by shadowing. In a study evaluating a 30-week shadowing program at the Pediatric Continuity Clinic in Los Angeles, California, a greater proportion of premedical students believed they had a good understanding of the job of a resident physician after the program’s completion compared to before starting the program (an increase from 78% to 100%).¹⁰ The proportion of students reporting a good understanding of the patient-physician relationship after completing the program also increased from 33% to 78%. Furthermore, 72% of the residents stated that having the undergraduates in the clinic was a positive experience.¹⁰ Thus, increasing shadowing opportunities is one extremely effective way to increase student knowledge and awareness of and exposure to dermatology.

Dermatology Mentors—Although 32% of students were interested in dermatology, 3% of students had mentorship in dermatology. In prior studies, it has been shown that mentorship is of great importance in student success and interest in pursuing a specialty. A report from the Association of American Medical Colleges 2019 Medical School Graduation Questionnaire found that the third most influential factor (52.1%) in specialty selection was role model influence.¹¹ In fact, having a role model is consistently one of the top 3 influences on student specialty choice and interest in the last 5 years of survey research. Some studies also have shown mentorship as a positive influence in specialty interest at the undergraduate and graduate levels. A study on an undergraduate student interest group noted that surgeon mentorship and exposure were positive factors to students’ interests in surgery.¹² In fact, the Association of American Medical Colleges noted that some surgical specialties, such as orthopedic surgery, had 45% of respondents who were interested in the specialty before medical school pursue their initial preference in medical school.¹³ Another survey corroborated these findings; more orthopedic-bound students compared with other specialties indicated they were more likely to pursue their field because of experiences prior to medical school.¹⁴

One of the reasons students might not have been exposed to as many opportunities for mentorship in dermatology is because the specialty is one of the smaller fields in medicine and tends to be concentrated in more well-resourced metropolitan areas.¹⁵ Dermatologists make up only 1.3% of the physician workforce.¹⁶ Because there might not be as much exposure to the field, students might also explore their interests in dermatology through other fields, such as through shadowing and observing primary care physicians who often treat patients with dermatologic issues. Skin diseases are a common reason for primary care visits, and one study suggested dermatologic diseases can make up approximately 8.4% of visits in primary care.¹⁷

Moreover, only 1% of medical schools require an elective in dermatology.¹⁸ With exposure being a crucial component to pursuing the specialty, it also is important to pursue formal mentorship within the specialty itself. One study noted that formal mentorship in dermatology was important for most (67%) respondents when considering the specialty; however, 39% of respondents mentioned receiving mentorship in the past. In fact, dermatology was one of the top 3 specialties for which respondents agreed that formal mentorship was important.¹⁹

Mentorship also has been shown to provide students with a variety of opportunities to develop personally and professionally. Some of these opportunities include increased confidence in their personal and professional success, increased desire to pursue a career in a field of interest, networking opportunities, career coaching, and support and research guidance.²⁰ A research study among medical students at Albert Einstein College of Medicine in New York, New York, found that US Medical Licensing Examination Step 1 scores, clinical grades, and the chance of not matching were important factors preventing them from applying to dermatology.²¹

Factors in Dermatology Residency Selection—A survey was conducted wherein 95 of 114 dermatology program directors expressed that among the top 5 criteria for dermatology resident selection were Step 1 scores and clinical grades, supporting the notion that academic factors were given a great emphasis during residency selection.²² Furthermore, among underrepresented minority medical students, a lack of diversity, the belief that minority students are seen negatively by residencies, socioeconomic factors, and not having mentors were major reasons for being dissuaded from applying to dermatology.²¹ These results showcase the heightened importance of mentors for underrepresented minority medical students in particular.

In graduate medical education, resources such as wikis, social networking sites, and blogs provide media through which trainees can communicate, exchange ideas, and enhance their medical knowledge.^23,24 A survey of 9606 osteopathic medical students showed that 35% of 992 respondents had used social media to learn more about residencies, and 10% believed that social media had influenced their choice of residency.²⁵ Given the impact social media has on recruitment, it also can be employed in a similar manner by dermatologists and dermatology residency programs to attract younger students to the field.

Access to More Opportunities to Learn About Dermatology—Besides shadowing and mentorship, other avenues of exposure to dermatology are possible and should be considered. In our study, 80% of students agreed that they would attend an event that increases exposure to dermatology if held by the premedical group, which suggests that students are eager to learn more about the field and want access to more opportunities, which could include learning procedures such as suturing or how to use a dermatoscope, attending guest speaker events, or participating in Learn2Derm volunteer events.

Learn2Derm was a skin cancer prevention fair first organized by medical students at George Washington University in Washington, DC. Students and residents sought to deliver sunscreens to underserved areas in Washington, DC, as well as teach residents about the importance of skin health. Participating in such events could be an excellent opportunity for all students to gain exposure to important topics in dermatology.²⁶

General Opinions of Dermatology—General opinions about dermatology and medicine were collected from the students through the optional “Additional Comments” section. Major themes found in the comments included the desire for more opportunities, mentorship, exposure, connections, and a discussion of disparities faced by Black patients/students within dermatology. Students also expressed an interest in dermatology and the desire to learn more about the specialty. From these themes, it can be gleaned that students are open to and eager for more opportunities to gain exposure and connections, and increasing the number of minority dermatologists is of importance.

Limitations—An important limitation of this study was the potential for selection bias, as the sample was chosen from a population at one university, which is not representative of the general population. Further, we only sampled students who were premedical and likely from a UiM racial group due to the demographics of the student population at the university, but given that the goal of the survey was to understand exposure to dermatology in underrepresented groups, we believe it was the appropriate population to target. Additionally, results were not compared with other more represented racial groups to see if these findings were unique to UiM undergraduate students.

Conclusion

Among premedical students, dermatology is an area of great interest with minimal opportunities available for exposure and learning because it is a smaller specialty with fewer experiences available for shadowing and mentorship. Although most UiM premedical students who were surveyed were exposed to the field through either the media or being a dermatology patient, fewer were exposed to the field through clinical experiences (such as shadowing) or mentorship. Most respondents found dermatology to be interesting and have considered pursuing it as a career. In particular, race-concordant mentoring in dermatologic care was valued by many students in garnering their interest in the field.

Most UiM students wanted more exposure to dermatology-related opportunities as well as mentorship and connections. Increasing shadowing, research, pipeline programs, and general events geared to dermatology are some modalities that could help improve exposure to dermatology for UiM students, especially for those interested in pursuing the field. This increased exposure can help positively influence more UiM students to pursue dermatology and help close the diversity gap in the field. Additionally, many were interested in attending potential dermatology informational events.

Given the fact that dermatology is a small field and mentorship may be hard to access, increasing informational events may be a more reasonable approach to inspiring and supporting interest. These events could include learning how to use certain tools and techniques, guest speaker events, or participating in educational volunteer efforts such as Learn2Derm.²⁶

Future research should focus on identifying beneficial factors of UiM premedical students who retain an interest in dermatology throughout their careers and actually apply to dermatology programs and become dermatologists. Those who do not apply to the specialty can be identified to understand potential dissuading factors and obstacles. Ultimately, more research and development of exposure opportunities, including mentorship programs and informational events, can be used to close the gap and improve diversity and health outcomes in dermatology.

Diversity of health care professionals improves medical outcomes and quality of life in patients. ¹ There is a lack of diversity in dermatology, with only 4.2% of dermatologists identifying as Hispanic and 3% identifying as African American, ² possibly due to a lack of early exposure to dermatology among high school and undergraduate students, a low number of underrepresented students in medical school, a lack of formal mentorship programs geared to underrepresented students, and implicit biases. ^1-4 Furthermore, the field is competitive, with many more applicants than available positions. In 2022, there were 851 applicants competing for 492 residency positions in dermatology. ⁵ Thus, it is important to educate young students about dermatology and understand root causes as to why the number of u nderrepresented in medicine (UiM) dermatologists remains stagnant.

According to Pritchett et al,⁴ it is crucial for dermatologists to interact with high school and college students to foster an early interest in dermatology. Many racial minority students do not progress from high school to college and then from college to medical school, which leaves a substantially reduced number of eligible UiM applicants who can progress into dermatology.⁶ Increasing the amount of UiM students going to medical school requires early mediation. Collaborating with pre-existing premedical school organizations through presentations and workshops is another way to promote an early interest in dermatology.⁴ Special consideration should be given to students who are UiM.

Among the general medical school curriculum, requirements for exposure to dermatology are not high. In one study, the median number of clinical and preclinical hours required was 10. Furthermore, 20% of 33 medical schools did not require preclinical dermatology hours (hours done before medical school rotations begin and in an academic setting), 36% required no clinical hours (rotational hours), 8% required no dermatology hours whatsoever, and only 10% required clinical dermatology rotation.³ Based on these findings, it is clear that dermatology is not well incorporated into medical school curricula. Furthermore, curricula have historically neglected to display adequate representation of skin of color.⁷ As a result, medical students generally have limited exposure to dermatology³ and are exposed even less to presentations of dermatologic issues in historically marginalized populations.⁷

Given the paucity of research on UiM students’ perceptions of dermatology prior to medical school, our cross-sectional survey study sought to evaluate the level of interest in dermatology of UiM premedical undergraduates. This survey specifically evaluated exposure to dermatology, preconceived notions about the field, and mentorship opportunities. By understanding these factors, dermatologists and dermatology residency programs can use this information to create mentorship opportunities and better adjust existing programs to meet students’ needs.

Methods

A 19-question multiple-choice survey was administered electronically (SurveyMonkey) in May 2020 to premedical students at Howard University (Washington, DC). One screening question was used: “What is your major?” Those who considered themselves a science major and/or with premedical interest were allowed to complete the survey. All students surveyed were members of the Health Professions Society at Howard University. Students who were interested in pursuing medical school were invited to respond. Approval for this study was obtained from the Howard University institutional review board (FWA00000891).

The survey was divided into 3 sections: Demographics, Exposure to Medicine and Dermatology, and Perceptions of Dermatology. The Demographics section addressed gender, age, and race/ethnicity. The Exposure to Medicine and Dermatology section addressed interest in attending medical school, shadowing experience, exposure to dermatology, and mentoring. The Perceptions of Dermatology section addressed preconceived notions about the field (eg, “dermatology is interesting and exciting”).

Statistical Analysis—The data represented are percentages based on the number of respondents who answered each question. Answers in response to “Please enter any comments” were organized into themes, and the number of respondents who discussed each theme was quantified into a table.

A total of 271 survey invitations were sent to premedical students at Howard University. Students were informed of the study protocol and asked to consent before proceeding to have their responses anonymously collected. Based on the screening question, 152 participants qualified for the survey, and 152 participants completed it (response rate, 56%; completion rate, 100%). Participants were asked to complete the survey only once.

Demographics—Eighty-four percent of respondents identified as science majors, and the remaining 16% identified as nonscience premedical. Ninety-four percent of participants identified as Black or African American; 3% as Asian or Asian American; and the remaining 3% as Other. Most respondents were female (82%), 16% were male, and 2% were either nonbinary or preferred not to answer. Ninety-nine percent were aged 18 to 24 years, and 1% were aged 25 to 34 years (Table 1).

Exposure to Medicine and Dermatology—Ninety-three percent of participants planned on attending medical school, and most students developed an interest in medicine from an early age. Ninety-six percent cited that they became interested in medicine prior to beginning their undergraduate education, and 4% developed an interest as freshmen or sophomores. When asked what led to their interest in medicine, family influence had the single greatest impact on students’ decision to pursue medicine (33%). Classes/school were the second most influential factor (24%), followed by volunteering (15%), shadowing (13%), other (7%), and peer influence (3%)(Figure 1).

Many (56%) premedical students surveyed had shadowing experience to varying degrees. Approximately 18% had fewer than 8 hours of shadowing experience, 24% had 8 to 40 hours, and 14% had more than 40 hours. However, many (43%) premedical students had no shadowing experience (Figure 2). Similarly, 30% of premedical students responded to having a physician as a mentor.

Regarding exposure to dermatology, 42% of premedical students had none. However, 58% of students had exposure to dermatology by being a patient themselves, 40% through seeing a dermatologist with a family member, 21% through seeing a dermatologist on television or social media, 5% through shadowing or volunteering, 3% through mentorship, and 1% through dermatology research (Figure 3).

Of students who said they were interested in dermatology (32%), 16% developed their interest before undergraduate education, while 9% developed interest in their freshman or sophomore year and 7% in their junior or senior year of undergraduate education. Three percent of respondents indicated that they had a dermatology mentorship.

Perceptions of Dermatology—To further evaluate the level of interest that UiM premedical students have in the field of dermatology, students were asked how much they agree or disagree on whether the field of dermatology is interesting. Sixty-three percent of the students agreed that the field of dermatology is interesting, 34% remained uncertain, and 3% disagreed. Additionally, students were asked whether they would consider dermatology as a career; 54% of respondents would consider dermatology as a career, 30% remained uncertain, and 16% would not consider dermatology as a career choice.

Nearly all (95%) students agreed that dermatologists do valuable work that goes beyond the scope of cosmetic procedures such as neuromodulators, fillers, chemical peels, and lasers. Some students also noted they had personal experiences interacting with a dermatologist. For example, one student described visiting the dermatologist many times to get a treatment regimen for their eczema.

Overall themes from the survey are depicted in Table 2. Major themes found in the comments included the desire for more dermatology-related opportunities, mentorship, exposure, connections, and a discussion of disparities faced by Black patients and students within dermatology. Students also expressed an interest in dermatology and the desire to learn more about the specialty.

Comment

Interest in Dermatology—In this cross-sectional survey study of 152 UiM undergraduate students, it was found that many students were interested in dermatology as a career, and more than 70% would be interested in attending events that increased exposure to the field of dermatology. Of the students who had any exposure to dermatology, less than 5% had shadowed an actual dermatologist. The survey showed that there is great potential interest in exposing UiM undergraduate students to the field of dermatology. We found that UiM students are interested in learning more about dermatology, with 80% indicating that they would be willing to participate in dermatology-focused events if they were available. Overall, students mentioned a lack of opportunities, mentorship, exposure, and connections in dermatology despite their interest in the field.

Racial Disparities in Dermatology—Additionally, students discussed disparities they encountered with dermatology due to a lack of patient-provider race concordance and the perceived difference in care when encountering a race-concordant dermatologist. One student noted that they went to multiple White dermatologists for their eczema, and “it wasn’t until I was evaluated by a Black dermatologist (diagnosed with eczema as well) [that I was] prescribed . . . the perfect medication.” Another student noted how a Black dermatologist sparked their interest in getting to know more about the field and remarked that they “think it is an important field that lacks representation for Black people.” This research stresses the need for more dermatology mentorship among UiM undergraduates.

Family Influence on Career Selection—The majority of UiM students in our study became interested in medicine because of family, which is consistent with other studies. In a cross-sectional survey of 300 Pakistani students (150 medical and 150 nonmedical), 87% of students stated that their family had an influence on their career selection.⁸ In another study of 15 junior doctors in Sierra Leone, the most common reasons for pursuing medicine were the desire to help and familial and peer influence.⁹ This again showcases how family can have a positive impact on career selection for medical professionals and highlights the need for early intervention.

Shadowing—One way in which student exposure to dermatology can be effectively increased is by shadowing. In a study evaluating a 30-week shadowing program at the Pediatric Continuity Clinic in Los Angeles, California, a greater proportion of premedical students believed they had a good understanding of the job of a resident physician after the program’s completion compared to before starting the program (an increase from 78% to 100%).¹⁰ The proportion of students reporting a good understanding of the patient-physician relationship after completing the program also increased from 33% to 78%. Furthermore, 72% of the residents stated that having the undergraduates in the clinic was a positive experience.¹⁰ Thus, increasing shadowing opportunities is one extremely effective way to increase student knowledge and awareness of and exposure to dermatology.

Dermatology Mentors—Although 32% of students were interested in dermatology, 3% of students had mentorship in dermatology. In prior studies, it has been shown that mentorship is of great importance in student success and interest in pursuing a specialty. A report from the Association of American Medical Colleges 2019 Medical School Graduation Questionnaire found that the third most influential factor (52.1%) in specialty selection was role model influence.¹¹ In fact, having a role model is consistently one of the top 3 influences on student specialty choice and interest in the last 5 years of survey research. Some studies also have shown mentorship as a positive influence in specialty interest at the undergraduate and graduate levels. A study on an undergraduate student interest group noted that surgeon mentorship and exposure were positive factors to students’ interests in surgery.¹² In fact, the Association of American Medical Colleges noted that some surgical specialties, such as orthopedic surgery, had 45% of respondents who were interested in the specialty before medical school pursue their initial preference in medical school.¹³ Another survey corroborated these findings; more orthopedic-bound students compared with other specialties indicated they were more likely to pursue their field because of experiences prior to medical school.¹⁴

One of the reasons students might not have been exposed to as many opportunities for mentorship in dermatology is because the specialty is one of the smaller fields in medicine and tends to be concentrated in more well-resourced metropolitan areas.¹⁵ Dermatologists make up only 1.3% of the physician workforce.¹⁶ Because there might not be as much exposure to the field, students might also explore their interests in dermatology through other fields, such as through shadowing and observing primary care physicians who often treat patients with dermatologic issues. Skin diseases are a common reason for primary care visits, and one study suggested dermatologic diseases can make up approximately 8.4% of visits in primary care.¹⁷

Moreover, only 1% of medical schools require an elective in dermatology.¹⁸ With exposure being a crucial component to pursuing the specialty, it also is important to pursue formal mentorship within the specialty itself. One study noted that formal mentorship in dermatology was important for most (67%) respondents when considering the specialty; however, 39% of respondents mentioned receiving mentorship in the past. In fact, dermatology was one of the top 3 specialties for which respondents agreed that formal mentorship was important.¹⁹

Mentorship also has been shown to provide students with a variety of opportunities to develop personally and professionally. Some of these opportunities include increased confidence in their personal and professional success, increased desire to pursue a career in a field of interest, networking opportunities, career coaching, and support and research guidance.²⁰ A research study among medical students at Albert Einstein College of Medicine in New York, New York, found that US Medical Licensing Examination Step 1 scores, clinical grades, and the chance of not matching were important factors preventing them from applying to dermatology.²¹

Factors in Dermatology Residency Selection—A survey was conducted wherein 95 of 114 dermatology program directors expressed that among the top 5 criteria for dermatology resident selection were Step 1 scores and clinical grades, supporting the notion that academic factors were given a great emphasis during residency selection.²² Furthermore, among underrepresented minority medical students, a lack of diversity, the belief that minority students are seen negatively by residencies, socioeconomic factors, and not having mentors were major reasons for being dissuaded from applying to dermatology.²¹ These results showcase the heightened importance of mentors for underrepresented minority medical students in particular.

In graduate medical education, resources such as wikis, social networking sites, and blogs provide media through which trainees can communicate, exchange ideas, and enhance their medical knowledge.^23,24 A survey of 9606 osteopathic medical students showed that 35% of 992 respondents had used social media to learn more about residencies, and 10% believed that social media had influenced their choice of residency.²⁵ Given the impact social media has on recruitment, it also can be employed in a similar manner by dermatologists and dermatology residency programs to attract younger students to the field.

Access to More Opportunities to Learn About Dermatology—Besides shadowing and mentorship, other avenues of exposure to dermatology are possible and should be considered. In our study, 80% of students agreed that they would attend an event that increases exposure to dermatology if held by the premedical group, which suggests that students are eager to learn more about the field and want access to more opportunities, which could include learning procedures such as suturing or how to use a dermatoscope, attending guest speaker events, or participating in Learn2Derm volunteer events.

Learn2Derm was a skin cancer prevention fair first organized by medical students at George Washington University in Washington, DC. Students and residents sought to deliver sunscreens to underserved areas in Washington, DC, as well as teach residents about the importance of skin health. Participating in such events could be an excellent opportunity for all students to gain exposure to important topics in dermatology.²⁶

General Opinions of Dermatology—General opinions about dermatology and medicine were collected from the students through the optional “Additional Comments” section. Major themes found in the comments included the desire for more opportunities, mentorship, exposure, connections, and a discussion of disparities faced by Black patients/students within dermatology. Students also expressed an interest in dermatology and the desire to learn more about the specialty. From these themes, it can be gleaned that students are open to and eager for more opportunities to gain exposure and connections, and increasing the number of minority dermatologists is of importance.

Limitations—An important limitation of this study was the potential for selection bias, as the sample was chosen from a population at one university, which is not representative of the general population. Further, we only sampled students who were premedical and likely from a UiM racial group due to the demographics of the student population at the university, but given that the goal of the survey was to understand exposure to dermatology in underrepresented groups, we believe it was the appropriate population to target. Additionally, results were not compared with other more represented racial groups to see if these findings were unique to UiM undergraduate students.

Conclusion

Among premedical students, dermatology is an area of great interest with minimal opportunities available for exposure and learning because it is a smaller specialty with fewer experiences available for shadowing and mentorship. Although most UiM premedical students who were surveyed were exposed to the field through either the media or being a dermatology patient, fewer were exposed to the field through clinical experiences (such as shadowing) or mentorship. Most respondents found dermatology to be interesting and have considered pursuing it as a career. In particular, race-concordant mentoring in dermatologic care was valued by many students in garnering their interest in the field.

Most UiM students wanted more exposure to dermatology-related opportunities as well as mentorship and connections. Increasing shadowing, research, pipeline programs, and general events geared to dermatology are some modalities that could help improve exposure to dermatology for UiM students, especially for those interested in pursuing the field. This increased exposure can help positively influence more UiM students to pursue dermatology and help close the diversity gap in the field. Additionally, many were interested in attending potential dermatology informational events.

Given the fact that dermatology is a small field and mentorship may be hard to access, increasing informational events may be a more reasonable approach to inspiring and supporting interest. These events could include learning how to use certain tools and techniques, guest speaker events, or participating in educational volunteer efforts such as Learn2Derm.²⁶

Future research should focus on identifying beneficial factors of UiM premedical students who retain an interest in dermatology throughout their careers and actually apply to dermatology programs and become dermatologists. Those who do not apply to the specialty can be identified to understand potential dissuading factors and obstacles. Ultimately, more research and development of exposure opportunities, including mentorship programs and informational events, can be used to close the gap and improve diversity and health outcomes in dermatology.

Dermatology providers are at an increased risk for blood-borne pathogen (BBP) exposures during procedures in clinical practice.^1-3 Current data regarding the characterization of these exposures are limited. Prior studies are based on surveys that result in low response rates and potential for selection bias. Donnelly et al¹ reported a 26% response rate in a national survey-based study evaluating BBP exposures in resident physicians, fellows, and practicing dermatologists, with 85% of respondents reporting at least 1 injury. Similarly, Goulart et al² reported a 35% response rate in a survey evaluating sharps injuries in residents and medical students, with 85% reporting a sharps injury. In addition, there are conflicting data regarding characteristics of these exposures, including common implicated instruments and procedures.^1-3 Prior studies also have not evaluated exposures in all members of dermatologic staff, including resident physicians, practicing dermatologists, and ancillary staff.

To make appropriate quality improvements in dermatologic procedures, a more comprehensive understanding of BBP exposures is needed. We conducted a retrospective review of BBP incidence reports to identify the incidence of BBP events among all dermatologic staff, including resident physicians, practicing dermatologists, and ancillary staff. We further investigated the type of exposure, the type of procedure associated with each exposure, anatomic locations of exposures, and instruments involved in each exposure.

Methods

Data on BBP exposures in the dermatology departments were obtained from the occupational health departments at each of 3 Mayo Clinic sites—Scottsdale, Arizona; Jacksonville, Florida; and Rochester, Minnesota—from March 2010 through January 2021. The institutional review board at Mayo Clinic, Scottsdale, Arizona, granted approval of this study (IRB #20-012625). A retrospective review of each exposure was conducted to identify the incidence of BBP exposures. Occupational BBP exposure was defined as any percutaneous injury or mucosal exposure with foreign blood, tissue, or other bodily fluids that placed the health care worker at risk for communicable infections. Secondary aims included identification of the type of exposure, type of procedure associated with each exposure, common anatomic locations of exposures, and common instruments involved in each exposure.

Statistical Analysis—Variables were summarized using counts and percentages. The 3 most common categories for each variable were then compared among occupational groups using the Fisher exact test. All other categories were grouped for analysis purposes. Medical staff were categorized into 3 occupational groups: practicing dermatologists; resident physicians; and ancillary staff, including nurse/medical assistants, physician assistants, and clinical laboratory technologists. All analyses were 2 sided and considered statistically significant at P<.05. Analyses were performed using SAS 9.4 (SAS Institute Inc).

Results

Type of Exposure—A total of 222 BBP exposures were identified through the trisite retrospective review from March 2010 through January 2021. One hundred ninety-nine (89.6%) of 222 exposures were attributed to needlesticks and medical sharps, while 23 (10.4%) of 222 exposures were attributed to splash incidents (Table).

Anatomic Sites Affected—The anatomic location most frequently involved was the thumb (130/217 events [59.9%]), followed by the hand (39/217 events [18.0%]) and finger (22/217 events [10.1%]). The arm, face, and knee were affected with the lowest frequency, with only 1 event reported at each anatomic site (0.5%)(eTable). Five incidents were excluded from the analysis of anatomic location because of insufficient details of events.

Incident Tasks and Tools—Most BBP exposures occurred during suturing or assisting with suturing (64/210 events [30.5%]), followed by handling of sharps, wires, or instruments (40/210 events [19.0%]) and medication administration (37/210 events [17.6%])(eTable). Twelve incidents were excluded from the analysis of implicated tasks because of insufficient details of events.

The tools involved in exposure events with the greatest prevalence included the suture needle (76/201 events [37.8%]), injection syringe/needle (43/201 events [21.4%]), and shave biopsy razor (24/201 events [11.9%])(eTable). Twenty-one incidents were excluded from the analysis of implicated instruments because of insufficient details of events.

Providers Affected by BBP Exposures—Resident physicians experienced the greatest number of BBP exposures (105/222 events [47.3%]), followed by ancillary providers (84/222 events [37.8%]) and practicing dermatologists (33/222 events [14.9%]). All occupational groups experienced more BBP exposures through needlesticks/medical sharps compared with splash incidents (resident physicians, 88.6%; ancillary staff, 91.7%; practicing dermatologists, 87.9%; P=.725)(Table).

Among resident physicians, practicing dermatologists, and ancillary staff, the most frequent site of injury was the thumb. Suturing/assisting with suturing was the most common task leading to injury, and the suture needle was the most common instrument of injury for both resident physicians and practicing dermatologists. Handling of sharps, wires, or instruments was the most common task leading to injury for ancillary staff, and the injection syringe/needle was the most common instrument of injury in this cohort.

Resident physicians experienced the lowest rate of BBP exposures during administration of medications (12.7%; P=.003). Ancillary staff experienced the highest rate of BBP exposures with an injection needle (35.5%; P=.001). There were no statistically significant differences among occupational groups for the anatomic location of injury (P=.074)(eTable).

Comment

In the year 2000, the annual global incidence of occupational BBP exposures among health care workers worldwide for hepatitis B virus, hepatitis C virus, and HIV was estimated at 2.1 million, 926,000, and 327,000, respectively. Most of these exposures were due to sharps injuries.⁴ Dermatologists are particularly at risk for BBP exposures given their reliance on frequent procedures in practice. During an 11-year period, 222 BBP exposures were documented in the dermatology departments at 3 Mayo Clinic institutions. Most exposures were due to needlestick/sharps across all occupational groups compared with splash injuries. Prior survey studies confirm that sharps injuries are frequently implicated, with 75% to 94% of residents and practicing dermatologists reporting at least 1 sharps injury.¹

Among occupational groups, resident physicians had the highest rate of BBP exposures, followed by nurse/medical assistants and practicing dermatologists, which may be secondary to lack of training or experience. Data from other surgical fields, including general surgery, support that resident physicians have the highest rate of sharps injuries.⁵ In a survey study (N=452), 51% of residents reported that extra training in safe techniques would be beneficial.² Safety training may be beneficial in reducing the incidence of BBP exposures in residency programs.

The most common implicated task in resident physicians and practicing dermatologists was suturing or assisting with suturing, and the most common implicated instrument was the suture needle. Prior studies showed conflicting data regarding common implicated tasks and instruments in this cohort.^1,2 The task of suturing and the suture needle also were the most implicated means of injury among other surgical specialties.⁶ Ancillary staff experienced most BBP exposures during handling of sharps, wires, or instruments, as well as the use of an injection needle. The designation of tasks among dermatologic staff likely explains the difference among occupational groups. This new information may provide the opportunity to improve safety measures among all members of the dermatologic team.

Limitations—There are several limitations to this study. This retrospective review was conducted at a single health system at 3 institutions. Hence, similar safety protocols likely were in place across all sites, which may reduce the generalizability of the results. In addition, there is risk of nonreporting bias among staff, as only documented incidence reports were evaluated. Prior studies demonstrated a nonreporting prevalence of 33% to 64% among dermatology staff.^1-3 We also did not evaluate whether injuries resulted in BBP exposure or transmission. The rates of postexposure prophylaxis also were not studied. This information was not available for review because of concerns for privacy. Demographic features, such as gender or years of training, also were not evaluated.

Conclusion

This study provides additional insight on the incidence of BBP exposures in dermatology, as well as the implicated tasks, instruments, and anatomic locations of injury. Studies show that implementing formal education regarding the risks of BBP exposure may result in reduction of sharps injuries.⁷ Formal education in residency programs may be needed in the field of dermatology to reduce BBP exposures. Quality improvement measures should focus on identified risk factors among occupational groups to reduce BBP exposures in the workplace.

Dermatology providers are at an increased risk for blood-borne pathogen (BBP) exposures during procedures in clinical practice.^1-3 Current data regarding the characterization of these exposures are limited. Prior studies are based on surveys that result in low response rates and potential for selection bias. Donnelly et al¹ reported a 26% response rate in a national survey-based study evaluating BBP exposures in resident physicians, fellows, and practicing dermatologists, with 85% of respondents reporting at least 1 injury. Similarly, Goulart et al² reported a 35% response rate in a survey evaluating sharps injuries in residents and medical students, with 85% reporting a sharps injury. In addition, there are conflicting data regarding characteristics of these exposures, including common implicated instruments and procedures.^1-3 Prior studies also have not evaluated exposures in all members of dermatologic staff, including resident physicians, practicing dermatologists, and ancillary staff.

To make appropriate quality improvements in dermatologic procedures, a more comprehensive understanding of BBP exposures is needed. We conducted a retrospective review of BBP incidence reports to identify the incidence of BBP events among all dermatologic staff, including resident physicians, practicing dermatologists, and ancillary staff. We further investigated the type of exposure, the type of procedure associated with each exposure, anatomic locations of exposures, and instruments involved in each exposure.

Methods

Data on BBP exposures in the dermatology departments were obtained from the occupational health departments at each of 3 Mayo Clinic sites—Scottsdale, Arizona; Jacksonville, Florida; and Rochester, Minnesota—from March 2010 through January 2021. The institutional review board at Mayo Clinic, Scottsdale, Arizona, granted approval of this study (IRB #20-012625). A retrospective review of each exposure was conducted to identify the incidence of BBP exposures. Occupational BBP exposure was defined as any percutaneous injury or mucosal exposure with foreign blood, tissue, or other bodily fluids that placed the health care worker at risk for communicable infections. Secondary aims included identification of the type of exposure, type of procedure associated with each exposure, common anatomic locations of exposures, and common instruments involved in each exposure.

Statistical Analysis—Variables were summarized using counts and percentages. The 3 most common categories for each variable were then compared among occupational groups using the Fisher exact test. All other categories were grouped for analysis purposes. Medical staff were categorized into 3 occupational groups: practicing dermatologists; resident physicians; and ancillary staff, including nurse/medical assistants, physician assistants, and clinical laboratory technologists. All analyses were 2 sided and considered statistically significant at P<.05. Analyses were performed using SAS 9.4 (SAS Institute Inc).

Results

Type of Exposure—A total of 222 BBP exposures were identified through the trisite retrospective review from March 2010 through January 2021. One hundred ninety-nine (89.6%) of 222 exposures were attributed to needlesticks and medical sharps, while 23 (10.4%) of 222 exposures were attributed to splash incidents (Table).

Anatomic Sites Affected—The anatomic location most frequently involved was the thumb (130/217 events [59.9%]), followed by the hand (39/217 events [18.0%]) and finger (22/217 events [10.1%]). The arm, face, and knee were affected with the lowest frequency, with only 1 event reported at each anatomic site (0.5%)(eTable). Five incidents were excluded from the analysis of anatomic location because of insufficient details of events.

Incident Tasks and Tools—Most BBP exposures occurred during suturing or assisting with suturing (64/210 events [30.5%]), followed by handling of sharps, wires, or instruments (40/210 events [19.0%]) and medication administration (37/210 events [17.6%])(eTable). Twelve incidents were excluded from the analysis of implicated tasks because of insufficient details of events.

The tools involved in exposure events with the greatest prevalence included the suture needle (76/201 events [37.8%]), injection syringe/needle (43/201 events [21.4%]), and shave biopsy razor (24/201 events [11.9%])(eTable). Twenty-one incidents were excluded from the analysis of implicated instruments because of insufficient details of events.

Providers Affected by BBP Exposures—Resident physicians experienced the greatest number of BBP exposures (105/222 events [47.3%]), followed by ancillary providers (84/222 events [37.8%]) and practicing dermatologists (33/222 events [14.9%]). All occupational groups experienced more BBP exposures through needlesticks/medical sharps compared with splash incidents (resident physicians, 88.6%; ancillary staff, 91.7%; practicing dermatologists, 87.9%; P=.725)(Table).

Among resident physicians, practicing dermatologists, and ancillary staff, the most frequent site of injury was the thumb. Suturing/assisting with suturing was the most common task leading to injury, and the suture needle was the most common instrument of injury for both resident physicians and practicing dermatologists. Handling of sharps, wires, or instruments was the most common task leading to injury for ancillary staff, and the injection syringe/needle was the most common instrument of injury in this cohort.

Resident physicians experienced the lowest rate of BBP exposures during administration of medications (12.7%; P=.003). Ancillary staff experienced the highest rate of BBP exposures with an injection needle (35.5%; P=.001). There were no statistically significant differences among occupational groups for the anatomic location of injury (P=.074)(eTable).

Comment

In the year 2000, the annual global incidence of occupational BBP exposures among health care workers worldwide for hepatitis B virus, hepatitis C virus, and HIV was estimated at 2.1 million, 926,000, and 327,000, respectively. Most of these exposures were due to sharps injuries.⁴ Dermatologists are particularly at risk for BBP exposures given their reliance on frequent procedures in practice. During an 11-year period, 222 BBP exposures were documented in the dermatology departments at 3 Mayo Clinic institutions. Most exposures were due to needlestick/sharps across all occupational groups compared with splash injuries. Prior survey studies confirm that sharps injuries are frequently implicated, with 75% to 94% of residents and practicing dermatologists reporting at least 1 sharps injury.¹

Among occupational groups, resident physicians had the highest rate of BBP exposures, followed by nurse/medical assistants and practicing dermatologists, which may be secondary to lack of training or experience. Data from other surgical fields, including general surgery, support that resident physicians have the highest rate of sharps injuries.⁵ In a survey study (N=452), 51% of residents reported that extra training in safe techniques would be beneficial.² Safety training may be beneficial in reducing the incidence of BBP exposures in residency programs.

The most common implicated task in resident physicians and practicing dermatologists was suturing or assisting with suturing, and the most common implicated instrument was the suture needle. Prior studies showed conflicting data regarding common implicated tasks and instruments in this cohort.^1,2 The task of suturing and the suture needle also were the most implicated means of injury among other surgical specialties.⁶ Ancillary staff experienced most BBP exposures during handling of sharps, wires, or instruments, as well as the use of an injection needle. The designation of tasks among dermatologic staff likely explains the difference among occupational groups. This new information may provide the opportunity to improve safety measures among all members of the dermatologic team.

Limitations—There are several limitations to this study. This retrospective review was conducted at a single health system at 3 institutions. Hence, similar safety protocols likely were in place across all sites, which may reduce the generalizability of the results. In addition, there is risk of nonreporting bias among staff, as only documented incidence reports were evaluated. Prior studies demonstrated a nonreporting prevalence of 33% to 64% among dermatology staff.^1-3 We also did not evaluate whether injuries resulted in BBP exposure or transmission. The rates of postexposure prophylaxis also were not studied. This information was not available for review because of concerns for privacy. Demographic features, such as gender or years of training, also were not evaluated.

Conclusion

This study provides additional insight on the incidence of BBP exposures in dermatology, as well as the implicated tasks, instruments, and anatomic locations of injury. Studies show that implementing formal education regarding the risks of BBP exposure may result in reduction of sharps injuries.⁷ Formal education in residency programs may be needed in the field of dermatology to reduce BBP exposures. Quality improvement measures should focus on identified risk factors among occupational groups to reduce BBP exposures in the workplace.

Dermatology providers are at an increased risk for blood-borne pathogen (BBP) exposures during procedures in clinical practice.^1-3 Current data regarding the characterization of these exposures are limited. Prior studies are based on surveys that result in low response rates and potential for selection bias. Donnelly et al¹ reported a 26% response rate in a national survey-based study evaluating BBP exposures in resident physicians, fellows, and practicing dermatologists, with 85% of respondents reporting at least 1 injury. Similarly, Goulart et al² reported a 35% response rate in a survey evaluating sharps injuries in residents and medical students, with 85% reporting a sharps injury. In addition, there are conflicting data regarding characteristics of these exposures, including common implicated instruments and procedures.^1-3 Prior studies also have not evaluated exposures in all members of dermatologic staff, including resident physicians, practicing dermatologists, and ancillary staff.

To make appropriate quality improvements in dermatologic procedures, a more comprehensive understanding of BBP exposures is needed. We conducted a retrospective review of BBP incidence reports to identify the incidence of BBP events among all dermatologic staff, including resident physicians, practicing dermatologists, and ancillary staff. We further investigated the type of exposure, the type of procedure associated with each exposure, anatomic locations of exposures, and instruments involved in each exposure.

Methods

Data on BBP exposures in the dermatology departments were obtained from the occupational health departments at each of 3 Mayo Clinic sites—Scottsdale, Arizona; Jacksonville, Florida; and Rochester, Minnesota—from March 2010 through January 2021. The institutional review board at Mayo Clinic, Scottsdale, Arizona, granted approval of this study (IRB #20-012625). A retrospective review of each exposure was conducted to identify the incidence of BBP exposures. Occupational BBP exposure was defined as any percutaneous injury or mucosal exposure with foreign blood, tissue, or other bodily fluids that placed the health care worker at risk for communicable infections. Secondary aims included identification of the type of exposure, type of procedure associated with each exposure, common anatomic locations of exposures, and common instruments involved in each exposure.

Statistical Analysis—Variables were summarized using counts and percentages. The 3 most common categories for each variable were then compared among occupational groups using the Fisher exact test. All other categories were grouped for analysis purposes. Medical staff were categorized into 3 occupational groups: practicing dermatologists; resident physicians; and ancillary staff, including nurse/medical assistants, physician assistants, and clinical laboratory technologists. All analyses were 2 sided and considered statistically significant at P<.05. Analyses were performed using SAS 9.4 (SAS Institute Inc).

Results

Type of Exposure—A total of 222 BBP exposures were identified through the trisite retrospective review from March 2010 through January 2021. One hundred ninety-nine (89.6%) of 222 exposures were attributed to needlesticks and medical sharps, while 23 (10.4%) of 222 exposures were attributed to splash incidents (Table).

Anatomic Sites Affected—The anatomic location most frequently involved was the thumb (130/217 events [59.9%]), followed by the hand (39/217 events [18.0%]) and finger (22/217 events [10.1%]). The arm, face, and knee were affected with the lowest frequency, with only 1 event reported at each anatomic site (0.5%)(eTable). Five incidents were excluded from the analysis of anatomic location because of insufficient details of events.

Incident Tasks and Tools—Most BBP exposures occurred during suturing or assisting with suturing (64/210 events [30.5%]), followed by handling of sharps, wires, or instruments (40/210 events [19.0%]) and medication administration (37/210 events [17.6%])(eTable). Twelve incidents were excluded from the analysis of implicated tasks because of insufficient details of events.

The tools involved in exposure events with the greatest prevalence included the suture needle (76/201 events [37.8%]), injection syringe/needle (43/201 events [21.4%]), and shave biopsy razor (24/201 events [11.9%])(eTable). Twenty-one incidents were excluded from the analysis of implicated instruments because of insufficient details of events.

Providers Affected by BBP Exposures—Resident physicians experienced the greatest number of BBP exposures (105/222 events [47.3%]), followed by ancillary providers (84/222 events [37.8%]) and practicing dermatologists (33/222 events [14.9%]). All occupational groups experienced more BBP exposures through needlesticks/medical sharps compared with splash incidents (resident physicians, 88.6%; ancillary staff, 91.7%; practicing dermatologists, 87.9%; P=.725)(Table).

Among resident physicians, practicing dermatologists, and ancillary staff, the most frequent site of injury was the thumb. Suturing/assisting with suturing was the most common task leading to injury, and the suture needle was the most common instrument of injury for both resident physicians and practicing dermatologists. Handling of sharps, wires, or instruments was the most common task leading to injury for ancillary staff, and the injection syringe/needle was the most common instrument of injury in this cohort.

Resident physicians experienced the lowest rate of BBP exposures during administration of medications (12.7%; P=.003). Ancillary staff experienced the highest rate of BBP exposures with an injection needle (35.5%; P=.001). There were no statistically significant differences among occupational groups for the anatomic location of injury (P=.074)(eTable).

Comment

In the year 2000, the annual global incidence of occupational BBP exposures among health care workers worldwide for hepatitis B virus, hepatitis C virus, and HIV was estimated at 2.1 million, 926,000, and 327,000, respectively. Most of these exposures were due to sharps injuries.⁴ Dermatologists are particularly at risk for BBP exposures given their reliance on frequent procedures in practice. During an 11-year period, 222 BBP exposures were documented in the dermatology departments at 3 Mayo Clinic institutions. Most exposures were due to needlestick/sharps across all occupational groups compared with splash injuries. Prior survey studies confirm that sharps injuries are frequently implicated, with 75% to 94% of residents and practicing dermatologists reporting at least 1 sharps injury.¹

Among occupational groups, resident physicians had the highest rate of BBP exposures, followed by nurse/medical assistants and practicing dermatologists, which may be secondary to lack of training or experience. Data from other surgical fields, including general surgery, support that resident physicians have the highest rate of sharps injuries.⁵ In a survey study (N=452), 51% of residents reported that extra training in safe techniques would be beneficial.² Safety training may be beneficial in reducing the incidence of BBP exposures in residency programs.

The most common implicated task in resident physicians and practicing dermatologists was suturing or assisting with suturing, and the most common implicated instrument was the suture needle. Prior studies showed conflicting data regarding common implicated tasks and instruments in this cohort.^1,2 The task of suturing and the suture needle also were the most implicated means of injury among other surgical specialties.⁶ Ancillary staff experienced most BBP exposures during handling of sharps, wires, or instruments, as well as the use of an injection needle. The designation of tasks among dermatologic staff likely explains the difference among occupational groups. This new information may provide the opportunity to improve safety measures among all members of the dermatologic team.

Limitations—There are several limitations to this study. This retrospective review was conducted at a single health system at 3 institutions. Hence, similar safety protocols likely were in place across all sites, which may reduce the generalizability of the results. In addition, there is risk of nonreporting bias among staff, as only documented incidence reports were evaluated. Prior studies demonstrated a nonreporting prevalence of 33% to 64% among dermatology staff.^1-3 We also did not evaluate whether injuries resulted in BBP exposure or transmission. The rates of postexposure prophylaxis also were not studied. This information was not available for review because of concerns for privacy. Demographic features, such as gender or years of training, also were not evaluated.

Conclusion

This study provides additional insight on the incidence of BBP exposures in dermatology, as well as the implicated tasks, instruments, and anatomic locations of injury. Studies show that implementing formal education regarding the risks of BBP exposure may result in reduction of sharps injuries.⁷ Formal education in residency programs may be needed in the field of dermatology to reduce BBP exposures. Quality improvement measures should focus on identified risk factors among occupational groups to reduce BBP exposures in the workplace.

Dermatology remains one of the most competitive specialties in medicine. In 2022, there were 851 applicants (613 doctor of medicine seniors, 85 doctor of osteopathic medicine seniors) for 492 postgraduate year (PGY) 2 positions.¹ During the 2022 application season, the average matched dermatology candidate had 7.2 research experiences; 20.9 abstracts, presentations, or publications; 11 volunteer experiences; and a US Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge score of 257.¹ With hopes of matching into such a competitive field, students often seek advice from academic dermatology mentors. Such advice may substantially differ based on each mentor and may or may not be evidence based.

We sought to analyze the range of advice given to medical students applying to dermatology residency programs via a survey to members of the Association of Professors of Dermatology (APD) with the intent to help applicants and mentors understand how letters of intent, letters of recommendation (LORs), and Electronic Residency Application Service (ERAS) supplemental applications are used by dermatology programs nationwide.

Methods

The study was reviewed by The Ohio State University institutional review board and was deemed exempt. A branching-logic survey with common questions from medical students while applying to dermatology residency programs (Table) was sent to all members of APD through the email listserve. Study data were collected and managed using REDCap electronic data capture tools hosted at The Ohio State University (Columbus, Ohio) to ensure data security.

The survey was distributed from August 28, 2022, to September 12, 2022. A total of 101 surveys were returned from 646 listserve members (15.6%). Given the branching-logic questions, differing numbers of responses were collected for each question. Descriptive statistics were utilized to analyze and report the results.

Results

Residency Program Number—Members of the APD were asked if they recommend students apply to a certain number of programs, and if so, how many programs. Of members who responded, 62.2% (61/98) either always (22.4% [22/98]) or sometimes (40.2% [39/97]) suggested students apply to a certain number of programs. When mentors made a recommendation, 54.1% (33/61) recommended applying to 59 or fewer programs, with only 9.8% (6/61) recommending students apply to 80 or more programs.

Gap Year—We queried mentors about their recommendations for a research gap year and asked which applicants should pursue this extra year. Our survey found that 74.5% of mentors (73/98) almost always (4.1% [4/98]) or sometimes (70.4% [69/98]) recommended a research gap year, most commonly for those applicants with a strong research interest (71.8% [51/71]). Other reasons mentors recommended a dedicated research year during medical school included low USMLE Step scores (50.7% [36/71]), low grades (45.1% [32/71]), little research (46.5% [33/71]), and no home program (43.7% [31/71]).

Internship Choices—Our survey results indicated that nearly two-thirds (63.3% [62/98]) of mentors did not give applicants a recommendation on type of internship (PGY-1). If a recommendation was given, academic dermatologists more commonly recommended an internal medicine preliminary year (29.6% [29/98]) over a transitional year (7.1% [7/98]).

Communication of Interest Via a Letter of Intent—We asked mentors if they recommended applicants send a letter of intent and conversely if receiving a letter of intent impacted their rank list. Nearly half (48.5% [47/97]) of mentors indicated they did not recommend sending a letter of intent, with only 15.5% (15/97) of mentors regularly recommending this practice. Additionally, 75.8% of mentors indicated that a letter of intent never (42.1% [40/95]) or rarely (33.7% [32/95]) impacted their rank list.

Rotation Choices—We queried mentors if they recommended students complete away rotations, and if so, how many rotations did they recommend. We found that 85.9% (85/99) of mentors recommended students complete an away rotation; 63.1% (53/84) of them recommended performing 2 away rotations, and 14.3% (12/84) of respondents recommended students complete 3 away rotations. More than a quarter of mentors (27.1% [23/85]) indicated their home medical schools limited the number of away rotations a medical student could complete in any 1 specialty, and 42.4% (36/85) of respondents were unsure if such a limitation existed.

Letters of Recommendation—Our survey asked respondents to rank various factors on a 5-point scale (1=not important; 5=very important) when deciding who should write the students’ LORs. Mentors indicated that the most important factor for letter-writer selection was how well the letter writer knows the applicant, with 90.8% (89/98) of mentors rating the importance of this quality as a 4 or 5 (Figure). More than half of respondents rated the name recognition of the letter writer and program director letter as a 4 or 5 in importance (54.1% [53/98] and 58.2% [57/98], respectively). Type of letter (standardized vs nonstandardized), title of letter writer, letters from an away rotation, and chair letter scored lower, with fewer than half of mentors rating these as a 4 or 5 in importance.

Supplemental Application—When asked about the 2022 application cycle, respondents of our survey reported that the supplemental application was overall more important in deciding which applicants to interview vs which to rank highly. Prior experiences were important (ranked 4 or 5) for 58.8% (57/97) of respondents in choosing applicants to interview, and 49.4% (48/97) of respondents thought prior experiences were important for ranking. Similarly, 34.0% (33/97) of mentors indicated geographic preference was important (ranked 4 or 5) for interview compared with only 23.8% (23/97) for ranking. Finally, 57.7% (56/97) of our survey respondents denoted that program signals were important or very important in choosing which applicants to interview, while 32.0% (31/97) indicated that program signals were important in ranking applicants.

Comment

Residency Programs: Which Ones, and How Many?—The number of applications for dermatology residency programs has increased 33.9% from 2010 to 2019.² The American Association of Medical Colleges Apply Smart data from 2013 to 2017 indicate that dermatology applicants arrive at a point of diminishing return between 37 and 62 applications, with variation within that range based on USMLE Step 1 score,³ and our data support this with nearly two-thirds of dermatology advisors recommending students apply within this range. Despite this data, dermatology residency applicants applied to more programs over the last decade (64.8 vs 77.0),² likely to maximize their chance of matching.

Research Gap Years During Medical School—Prior research has shown that nearly half of faculty indicated that a research year during medical school can distinguish similar applicants, and close to 25% of applicants completed a research gap year.^4,5 However, available data indicate that taking a research gap year has no effect on match rate or number of interview invites but does correlate with match rates at the highest ranked dermatology residency programs.^6-8

Our data indicate that the most commonly recommended reason for a research gap year was an applicants’ strong interest in research. However, nearly half of dermatology mentors recommended research years during medical school for reasons other than an interest in research. As research gap years increase in popularity, future research is needed to confirm the consequence of this additional year and which applicants, if any, will benefit from such a year.

Preferences for Intern Year—Prior research suggests that dermatology residency program directors favor PGY-1 preliminary medicine internships because of the rigor of training.^9,10 Our data continue to show a preference for internal medicine preliminary years over transitional years. However, given nearly two-thirds of dermatology mentors do not give applicants any recommendations on PGY-1 year, this preference may be fading.

Letters of Intent Not Recommended—Research in 2022 found that 78.8% of dermatology applicants sent a letter of intent communicating a plan to rank that program number 1, with nearly 13% sending such a letter to more than 1 program.¹¹ With nearly half of mentors in our survey actively discouraging this process and more than 75% of mentors not utilizing this letter, the APD issued a brief statement on the 2022-2023 application cycle stating, “Post-interview communication of preference—including ‘letters of intent’ and thank you letters—should not be sent to programs. These types of communication are typically not used by residency programs in decision-making and lead to downstream pressures on applicants.”¹²

Away Rotations—Prior to the COVID-19 pandemic, data demonstrated that nearly one-third of dermatology applicants (29%) matched at their home institution, and nearly one-fifth (18%) matched where they completed an away rotation.¹³ In-person away rotations were eliminated in 2020 and restricted to 1 away rotation in 2021. Restrictions regarding away rotations were removed in 2022. Our data indicate that dermatology mentors strongly supported an away rotation, with more than half of them recommending at least 2 away rotations.

Further research is needed to determine the effect numerous away rotations have on minimizing students’ exposure to other specialties outside their chosen field. Additionally, further studies are needed to determine the impact away rotations have on economically disadvantaged students, students without home programs, and students with families. In an effort to standardize the number of away rotations, the APD issued a statement for the 2023-2024 application cycle indicating that dermatology applicants should limit away rotations to 2 in-person electives. Students without a home dermatology program could consider completing up to 3 electives.¹⁴

Who Should Write LORs?—Research in 2014 demonstrated that LORs were very important in determining applicants to interview, with a strong preference for LORs from academic dermatologists and colleagues.¹⁵ Our data strongly indicated applicants should predominantly ask for letters from writers who know them well. The majority of mentors did not give value to the rank of the letter writer (eg, assistant professor, associate professor, professor), type of letter, chair letters, or letters from an away rotation. These data may help alleviate stress many students feel as they search for letter writers.

How is the Supplemental Application Used?—In 2022, the ERAS supplemental application was introduced, which allowed applicants to detail 5 meaningful experiences, describe impactful life challenges, and indicate preferences for geographic region. Dermatology residency applicants also were able to choose 3 residency programs to signal interest in that program. Our data found that the supplemental application was utilized predominantly to select applicants to interview, which is in line with the Association of American Medical Colleges’ and APD guidelines indicating that this tool is solely meant to assist with application review.¹⁶ Further research and data will hopefully inform approaches to best utilize the ERAS supplemental application data.

Limitations—Our data were limited by response rate and sample size, as only academic dermatologists belonging to the APD were queried. Additionally, we did not track personal information of the mentors, so more than 1 mentor may have responded from a single institution, making it possible that our data may not be broadly applicable to all institutions.

Conclusion

Although there is no algorithmic method of advising medical students who are interested in dermatology, our survey data help to describe the range of advice currently given to students, which can improve and guide future recommendations. Additionally, some of our data demonstrate a discrepancy between mentor advice and current medical student practice for the number of applications and use of a letter of intent. We hope our data will assist academic dermatology mentors in the provision of advice to mentees as well as inform organizations seeking to create standards and official recommendations regarding aspects of the application process.

Dermatology remains one of the most competitive specialties in medicine. In 2022, there were 851 applicants (613 doctor of medicine seniors, 85 doctor of osteopathic medicine seniors) for 492 postgraduate year (PGY) 2 positions.¹ During the 2022 application season, the average matched dermatology candidate had 7.2 research experiences; 20.9 abstracts, presentations, or publications; 11 volunteer experiences; and a US Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge score of 257.¹ With hopes of matching into such a competitive field, students often seek advice from academic dermatology mentors. Such advice may substantially differ based on each mentor and may or may not be evidence based.

We sought to analyze the range of advice given to medical students applying to dermatology residency programs via a survey to members of the Association of Professors of Dermatology (APD) with the intent to help applicants and mentors understand how letters of intent, letters of recommendation (LORs), and Electronic Residency Application Service (ERAS) supplemental applications are used by dermatology programs nationwide.

Methods

The study was reviewed by The Ohio State University institutional review board and was deemed exempt. A branching-logic survey with common questions from medical students while applying to dermatology residency programs (Table) was sent to all members of APD through the email listserve. Study data were collected and managed using REDCap electronic data capture tools hosted at The Ohio State University (Columbus, Ohio) to ensure data security.

The survey was distributed from August 28, 2022, to September 12, 2022. A total of 101 surveys were returned from 646 listserve members (15.6%). Given the branching-logic questions, differing numbers of responses were collected for each question. Descriptive statistics were utilized to analyze and report the results.

Results

Residency Program Number—Members of the APD were asked if they recommend students apply to a certain number of programs, and if so, how many programs. Of members who responded, 62.2% (61/98) either always (22.4% [22/98]) or sometimes (40.2% [39/97]) suggested students apply to a certain number of programs. When mentors made a recommendation, 54.1% (33/61) recommended applying to 59 or fewer programs, with only 9.8% (6/61) recommending students apply to 80 or more programs.

Gap Year—We queried mentors about their recommendations for a research gap year and asked which applicants should pursue this extra year. Our survey found that 74.5% of mentors (73/98) almost always (4.1% [4/98]) or sometimes (70.4% [69/98]) recommended a research gap year, most commonly for those applicants with a strong research interest (71.8% [51/71]). Other reasons mentors recommended a dedicated research year during medical school included low USMLE Step scores (50.7% [36/71]), low grades (45.1% [32/71]), little research (46.5% [33/71]), and no home program (43.7% [31/71]).

Internship Choices—Our survey results indicated that nearly two-thirds (63.3% [62/98]) of mentors did not give applicants a recommendation on type of internship (PGY-1). If a recommendation was given, academic dermatologists more commonly recommended an internal medicine preliminary year (29.6% [29/98]) over a transitional year (7.1% [7/98]).

Communication of Interest Via a Letter of Intent—We asked mentors if they recommended applicants send a letter of intent and conversely if receiving a letter of intent impacted their rank list. Nearly half (48.5% [47/97]) of mentors indicated they did not recommend sending a letter of intent, with only 15.5% (15/97) of mentors regularly recommending this practice. Additionally, 75.8% of mentors indicated that a letter of intent never (42.1% [40/95]) or rarely (33.7% [32/95]) impacted their rank list.

Rotation Choices—We queried mentors if they recommended students complete away rotations, and if so, how many rotations did they recommend. We found that 85.9% (85/99) of mentors recommended students complete an away rotation; 63.1% (53/84) of them recommended performing 2 away rotations, and 14.3% (12/84) of respondents recommended students complete 3 away rotations. More than a quarter of mentors (27.1% [23/85]) indicated their home medical schools limited the number of away rotations a medical student could complete in any 1 specialty, and 42.4% (36/85) of respondents were unsure if such a limitation existed.

Letters of Recommendation—Our survey asked respondents to rank various factors on a 5-point scale (1=not important; 5=very important) when deciding who should write the students’ LORs. Mentors indicated that the most important factor for letter-writer selection was how well the letter writer knows the applicant, with 90.8% (89/98) of mentors rating the importance of this quality as a 4 or 5 (Figure). More than half of respondents rated the name recognition of the letter writer and program director letter as a 4 or 5 in importance (54.1% [53/98] and 58.2% [57/98], respectively). Type of letter (standardized vs nonstandardized), title of letter writer, letters from an away rotation, and chair letter scored lower, with fewer than half of mentors rating these as a 4 or 5 in importance.

Supplemental Application—When asked about the 2022 application cycle, respondents of our survey reported that the supplemental application was overall more important in deciding which applicants to interview vs which to rank highly. Prior experiences were important (ranked 4 or 5) for 58.8% (57/97) of respondents in choosing applicants to interview, and 49.4% (48/97) of respondents thought prior experiences were important for ranking. Similarly, 34.0% (33/97) of mentors indicated geographic preference was important (ranked 4 or 5) for interview compared with only 23.8% (23/97) for ranking. Finally, 57.7% (56/97) of our survey respondents denoted that program signals were important or very important in choosing which applicants to interview, while 32.0% (31/97) indicated that program signals were important in ranking applicants.

Comment

Residency Programs: Which Ones, and How Many?—The number of applications for dermatology residency programs has increased 33.9% from 2010 to 2019.² The American Association of Medical Colleges Apply Smart data from 2013 to 2017 indicate that dermatology applicants arrive at a point of diminishing return between 37 and 62 applications, with variation within that range based on USMLE Step 1 score,³ and our data support this with nearly two-thirds of dermatology advisors recommending students apply within this range. Despite this data, dermatology residency applicants applied to more programs over the last decade (64.8 vs 77.0),² likely to maximize their chance of matching.

Research Gap Years During Medical School—Prior research has shown that nearly half of faculty indicated that a research year during medical school can distinguish similar applicants, and close to 25% of applicants completed a research gap year.^4,5 However, available data indicate that taking a research gap year has no effect on match rate or number of interview invites but does correlate with match rates at the highest ranked dermatology residency programs.^6-8

Our data indicate that the most commonly recommended reason for a research gap year was an applicants’ strong interest in research. However, nearly half of dermatology mentors recommended research years during medical school for reasons other than an interest in research. As research gap years increase in popularity, future research is needed to confirm the consequence of this additional year and which applicants, if any, will benefit from such a year.

Preferences for Intern Year—Prior research suggests that dermatology residency program directors favor PGY-1 preliminary medicine internships because of the rigor of training.^9,10 Our data continue to show a preference for internal medicine preliminary years over transitional years. However, given nearly two-thirds of dermatology mentors do not give applicants any recommendations on PGY-1 year, this preference may be fading.

Letters of Intent Not Recommended—Research in 2022 found that 78.8% of dermatology applicants sent a letter of intent communicating a plan to rank that program number 1, with nearly 13% sending such a letter to more than 1 program.¹¹ With nearly half of mentors in our survey actively discouraging this process and more than 75% of mentors not utilizing this letter, the APD issued a brief statement on the 2022-2023 application cycle stating, “Post-interview communication of preference—including ‘letters of intent’ and thank you letters—should not be sent to programs. These types of communication are typically not used by residency programs in decision-making and lead to downstream pressures on applicants.”¹²

Away Rotations—Prior to the COVID-19 pandemic, data demonstrated that nearly one-third of dermatology applicants (29%) matched at their home institution, and nearly one-fifth (18%) matched where they completed an away rotation.¹³ In-person away rotations were eliminated in 2020 and restricted to 1 away rotation in 2021. Restrictions regarding away rotations were removed in 2022. Our data indicate that dermatology mentors strongly supported an away rotation, with more than half of them recommending at least 2 away rotations.

Further research is needed to determine the effect numerous away rotations have on minimizing students’ exposure to other specialties outside their chosen field. Additionally, further studies are needed to determine the impact away rotations have on economically disadvantaged students, students without home programs, and students with families. In an effort to standardize the number of away rotations, the APD issued a statement for the 2023-2024 application cycle indicating that dermatology applicants should limit away rotations to 2 in-person electives. Students without a home dermatology program could consider completing up to 3 electives.¹⁴

Who Should Write LORs?—Research in 2014 demonstrated that LORs were very important in determining applicants to interview, with a strong preference for LORs from academic dermatologists and colleagues.¹⁵ Our data strongly indicated applicants should predominantly ask for letters from writers who know them well. The majority of mentors did not give value to the rank of the letter writer (eg, assistant professor, associate professor, professor), type of letter, chair letters, or letters from an away rotation. These data may help alleviate stress many students feel as they search for letter writers.

How is the Supplemental Application Used?—In 2022, the ERAS supplemental application was introduced, which allowed applicants to detail 5 meaningful experiences, describe impactful life challenges, and indicate preferences for geographic region. Dermatology residency applicants also were able to choose 3 residency programs to signal interest in that program. Our data found that the supplemental application was utilized predominantly to select applicants to interview, which is in line with the Association of American Medical Colleges’ and APD guidelines indicating that this tool is solely meant to assist with application review.¹⁶ Further research and data will hopefully inform approaches to best utilize the ERAS supplemental application data.

Limitations—Our data were limited by response rate and sample size, as only academic dermatologists belonging to the APD were queried. Additionally, we did not track personal information of the mentors, so more than 1 mentor may have responded from a single institution, making it possible that our data may not be broadly applicable to all institutions.

Conclusion

Although there is no algorithmic method of advising medical students who are interested in dermatology, our survey data help to describe the range of advice currently given to students, which can improve and guide future recommendations. Additionally, some of our data demonstrate a discrepancy between mentor advice and current medical student practice for the number of applications and use of a letter of intent. We hope our data will assist academic dermatology mentors in the provision of advice to mentees as well as inform organizations seeking to create standards and official recommendations regarding aspects of the application process.

Dermatology remains one of the most competitive specialties in medicine. In 2022, there were 851 applicants (613 doctor of medicine seniors, 85 doctor of osteopathic medicine seniors) for 492 postgraduate year (PGY) 2 positions.¹ During the 2022 application season, the average matched dermatology candidate had 7.2 research experiences; 20.9 abstracts, presentations, or publications; 11 volunteer experiences; and a US Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge score of 257.¹ With hopes of matching into such a competitive field, students often seek advice from academic dermatology mentors. Such advice may substantially differ based on each mentor and may or may not be evidence based.

We sought to analyze the range of advice given to medical students applying to dermatology residency programs via a survey to members of the Association of Professors of Dermatology (APD) with the intent to help applicants and mentors understand how letters of intent, letters of recommendation (LORs), and Electronic Residency Application Service (ERAS) supplemental applications are used by dermatology programs nationwide.

Methods

The study was reviewed by The Ohio State University institutional review board and was deemed exempt. A branching-logic survey with common questions from medical students while applying to dermatology residency programs (Table) was sent to all members of APD through the email listserve. Study data were collected and managed using REDCap electronic data capture tools hosted at The Ohio State University (Columbus, Ohio) to ensure data security.

The survey was distributed from August 28, 2022, to September 12, 2022. A total of 101 surveys were returned from 646 listserve members (15.6%). Given the branching-logic questions, differing numbers of responses were collected for each question. Descriptive statistics were utilized to analyze and report the results.

Results

Residency Program Number—Members of the APD were asked if they recommend students apply to a certain number of programs, and if so, how many programs. Of members who responded, 62.2% (61/98) either always (22.4% [22/98]) or sometimes (40.2% [39/97]) suggested students apply to a certain number of programs. When mentors made a recommendation, 54.1% (33/61) recommended applying to 59 or fewer programs, with only 9.8% (6/61) recommending students apply to 80 or more programs.

Gap Year—We queried mentors about their recommendations for a research gap year and asked which applicants should pursue this extra year. Our survey found that 74.5% of mentors (73/98) almost always (4.1% [4/98]) or sometimes (70.4% [69/98]) recommended a research gap year, most commonly for those applicants with a strong research interest (71.8% [51/71]). Other reasons mentors recommended a dedicated research year during medical school included low USMLE Step scores (50.7% [36/71]), low grades (45.1% [32/71]), little research (46.5% [33/71]), and no home program (43.7% [31/71]).

Internship Choices—Our survey results indicated that nearly two-thirds (63.3% [62/98]) of mentors did not give applicants a recommendation on type of internship (PGY-1). If a recommendation was given, academic dermatologists more commonly recommended an internal medicine preliminary year (29.6% [29/98]) over a transitional year (7.1% [7/98]).

Communication of Interest Via a Letter of Intent—We asked mentors if they recommended applicants send a letter of intent and conversely if receiving a letter of intent impacted their rank list. Nearly half (48.5% [47/97]) of mentors indicated they did not recommend sending a letter of intent, with only 15.5% (15/97) of mentors regularly recommending this practice. Additionally, 75.8% of mentors indicated that a letter of intent never (42.1% [40/95]) or rarely (33.7% [32/95]) impacted their rank list.

Rotation Choices—We queried mentors if they recommended students complete away rotations, and if so, how many rotations did they recommend. We found that 85.9% (85/99) of mentors recommended students complete an away rotation; 63.1% (53/84) of them recommended performing 2 away rotations, and 14.3% (12/84) of respondents recommended students complete 3 away rotations. More than a quarter of mentors (27.1% [23/85]) indicated their home medical schools limited the number of away rotations a medical student could complete in any 1 specialty, and 42.4% (36/85) of respondents were unsure if such a limitation existed.

Letters of Recommendation—Our survey asked respondents to rank various factors on a 5-point scale (1=not important; 5=very important) when deciding who should write the students’ LORs. Mentors indicated that the most important factor for letter-writer selection was how well the letter writer knows the applicant, with 90.8% (89/98) of mentors rating the importance of this quality as a 4 or 5 (Figure). More than half of respondents rated the name recognition of the letter writer and program director letter as a 4 or 5 in importance (54.1% [53/98] and 58.2% [57/98], respectively). Type of letter (standardized vs nonstandardized), title of letter writer, letters from an away rotation, and chair letter scored lower, with fewer than half of mentors rating these as a 4 or 5 in importance.

Supplemental Application—When asked about the 2022 application cycle, respondents of our survey reported that the supplemental application was overall more important in deciding which applicants to interview vs which to rank highly. Prior experiences were important (ranked 4 or 5) for 58.8% (57/97) of respondents in choosing applicants to interview, and 49.4% (48/97) of respondents thought prior experiences were important for ranking. Similarly, 34.0% (33/97) of mentors indicated geographic preference was important (ranked 4 or 5) for interview compared with only 23.8% (23/97) for ranking. Finally, 57.7% (56/97) of our survey respondents denoted that program signals were important or very important in choosing which applicants to interview, while 32.0% (31/97) indicated that program signals were important in ranking applicants.

Comment

Residency Programs: Which Ones, and How Many?—The number of applications for dermatology residency programs has increased 33.9% from 2010 to 2019.² The American Association of Medical Colleges Apply Smart data from 2013 to 2017 indicate that dermatology applicants arrive at a point of diminishing return between 37 and 62 applications, with variation within that range based on USMLE Step 1 score,³ and our data support this with nearly two-thirds of dermatology advisors recommending students apply within this range. Despite this data, dermatology residency applicants applied to more programs over the last decade (64.8 vs 77.0),² likely to maximize their chance of matching.

Research Gap Years During Medical School—Prior research has shown that nearly half of faculty indicated that a research year during medical school can distinguish similar applicants, and close to 25% of applicants completed a research gap year.^4,5 However, available data indicate that taking a research gap year has no effect on match rate or number of interview invites but does correlate with match rates at the highest ranked dermatology residency programs.^6-8

Our data indicate that the most commonly recommended reason for a research gap year was an applicants’ strong interest in research. However, nearly half of dermatology mentors recommended research years during medical school for reasons other than an interest in research. As research gap years increase in popularity, future research is needed to confirm the consequence of this additional year and which applicants, if any, will benefit from such a year.

Preferences for Intern Year—Prior research suggests that dermatology residency program directors favor PGY-1 preliminary medicine internships because of the rigor of training.^9,10 Our data continue to show a preference for internal medicine preliminary years over transitional years. However, given nearly two-thirds of dermatology mentors do not give applicants any recommendations on PGY-1 year, this preference may be fading.

Letters of Intent Not Recommended—Research in 2022 found that 78.8% of dermatology applicants sent a letter of intent communicating a plan to rank that program number 1, with nearly 13% sending such a letter to more than 1 program.¹¹ With nearly half of mentors in our survey actively discouraging this process and more than 75% of mentors not utilizing this letter, the APD issued a brief statement on the 2022-2023 application cycle stating, “Post-interview communication of preference—including ‘letters of intent’ and thank you letters—should not be sent to programs. These types of communication are typically not used by residency programs in decision-making and lead to downstream pressures on applicants.”¹²

Away Rotations—Prior to the COVID-19 pandemic, data demonstrated that nearly one-third of dermatology applicants (29%) matched at their home institution, and nearly one-fifth (18%) matched where they completed an away rotation.¹³ In-person away rotations were eliminated in 2020 and restricted to 1 away rotation in 2021. Restrictions regarding away rotations were removed in 2022. Our data indicate that dermatology mentors strongly supported an away rotation, with more than half of them recommending at least 2 away rotations.

Further research is needed to determine the effect numerous away rotations have on minimizing students’ exposure to other specialties outside their chosen field. Additionally, further studies are needed to determine the impact away rotations have on economically disadvantaged students, students without home programs, and students with families. In an effort to standardize the number of away rotations, the APD issued a statement for the 2023-2024 application cycle indicating that dermatology applicants should limit away rotations to 2 in-person electives. Students without a home dermatology program could consider completing up to 3 electives.¹⁴

Who Should Write LORs?—Research in 2014 demonstrated that LORs were very important in determining applicants to interview, with a strong preference for LORs from academic dermatologists and colleagues.¹⁵ Our data strongly indicated applicants should predominantly ask for letters from writers who know them well. The majority of mentors did not give value to the rank of the letter writer (eg, assistant professor, associate professor, professor), type of letter, chair letters, or letters from an away rotation. These data may help alleviate stress many students feel as they search for letter writers.

How is the Supplemental Application Used?—In 2022, the ERAS supplemental application was introduced, which allowed applicants to detail 5 meaningful experiences, describe impactful life challenges, and indicate preferences for geographic region. Dermatology residency applicants also were able to choose 3 residency programs to signal interest in that program. Our data found that the supplemental application was utilized predominantly to select applicants to interview, which is in line with the Association of American Medical Colleges’ and APD guidelines indicating that this tool is solely meant to assist with application review.¹⁶ Further research and data will hopefully inform approaches to best utilize the ERAS supplemental application data.

Limitations—Our data were limited by response rate and sample size, as only academic dermatologists belonging to the APD were queried. Additionally, we did not track personal information of the mentors, so more than 1 mentor may have responded from a single institution, making it possible that our data may not be broadly applicable to all institutions.

Conclusion

Although there is no algorithmic method of advising medical students who are interested in dermatology, our survey data help to describe the range of advice currently given to students, which can improve and guide future recommendations. Additionally, some of our data demonstrate a discrepancy between mentor advice and current medical student practice for the number of applications and use of a letter of intent. We hope our data will assist academic dermatology mentors in the provision of advice to mentees as well as inform organizations seeking to create standards and official recommendations regarding aspects of the application process.