For Residents

TAMPA, FLA. – Gender bias that disadvantages women from rising in academic medicine might require specific habit-changing strategies rather than efforts that draw on goodwill alone, according to new follow-up data from a randomized trial discussed and reevaluated at the annual meeting of the American College of Psychiatrists.

One premise of this trial, supported by other research, is that entrenched gender stereotypes drive both male and female behavior and must be addressed directly for change, said Molly Carnes, MD, professor of psychiatry at the University of Wisconsin, Madison.

The initial results of the trial, which randomized academic departments at the University of Wisconsin to participate in habit-changing workshops or to serve as controls, were published almost 3 years ago (Acad Med. 2015 Feb;90[2]:221-30). It is the most recent follow-up (Devine et al. J Exp Soc Psychol. 2017 Nov;73:211-5) that corroborates that long-term changes are possible with intervention.

The published findings showed that when 1,137 faculty members from 46 departments in the experimental arm were compared with 1,153 faculty members from 46 departments in the control arm, there were significant improvements in the experimental arm in surveyed attitudes reflecting personal bias awareness (P = .001) and willingness to support gender equity (P = .013).

These changes in attitude translated into concrete changes in new female faculty hires in the most recent analysis. From 32% in a 2-year period before the workshops, the new female hires climbed to 46% in the 2-year period after the workshops – a relative increase of 44% in the departments participating in the experimental arm. In the control departments, female new faculty hires remained at 32% in both time periods.

“Basically, there are 20 new women faculty members at the University of Wisconsin because of this study,” Dr. Carnes said.

The training was not designed to change just male faculty perceptions but perceptions of both males and females. The result was a fundamental change in culture within departments randomized to the experimental arm, according to data generated by a variety of study analyses.

“When we looked at questions about department climate, we found that both male and female faculty members in the experimental groups were significantly more likely to say they fit in their department, they felt respected for their research and scholarship by their colleagues, and they felt comfortable raising personal and family issues even if they conflicted with departmental activities,” Dr. Carnes said.

This general attitude change is important, because Dr. Carnes emphasized that women share the cultural biases that can result in reduced female career opportunities in clinical and academic medicine. In addition, women generally are aware that stereotypical positive “agentic” adjectives for men, such as decisive, competitive, and ambitious, often are viewed negatively and generate backlash when applied to women. They therefore act on this awareness.

“Stereotype-based bias is a habit that can be broken, but it requires more than good intentions,” said Dr. Carnes, who emphasized that “gender-based assumptions and stereotypes are deeply embedded in the patterns of thinking of both men and women.”

As one example, Dr. Carnes cited her work evaluating female resident behavior when leading in-hospital code resuscitations. There are data to show that there is no difference in the effectiveness of male and female resident code leaders, but women typically feel that the assertive, aggressive behavior required for code leadership is “counternormative.” After the code, some women feel compelled to apologize to team members for being demanding or assertive, a step that Dr. Carnes attributed at least in part to fear of backlash from stepping out of gender-expected behavior.

The fix is not necessarily suppression of gender-related attributes. Dr. Carnes cited evidence that the stereotypical positive communal adjectives for women, such as nurturing, supportive, and sympathetic, might explain why studies suggest that women are more likely than men to be transformational leaders who inspire team members to contribute beyond their own self-interest in achieving goals.

Ultimately, the fix is replacement of stereotypes that impair men as well as women from defusing biases that “lead to subtle unintentional advantages in academic career advancement for Jack not afforded to Jill,” Dr. Carnes said. Based on the low numbers of female leaders in academic medicine decades after medical schools began enrolling women in substantial numbers, she concluded that meaningful change in gender bias is not likely to occur without implementation of specific proactive strategies aimed at challenging current perceptions. Her published study confirms that such strategies can help.

Dr. Carnes reported no conflicts of interest.

cpnews@frontlinemedcom.com

TAMPA, FLA. – Gender bias that disadvantages women from rising in academic medicine might require specific habit-changing strategies rather than efforts that draw on goodwill alone, according to new follow-up data from a randomized trial discussed and reevaluated at the annual meeting of the American College of Psychiatrists.

One premise of this trial, supported by other research, is that entrenched gender stereotypes drive both male and female behavior and must be addressed directly for change, said Molly Carnes, MD, professor of psychiatry at the University of Wisconsin, Madison.

The initial results of the trial, which randomized academic departments at the University of Wisconsin to participate in habit-changing workshops or to serve as controls, were published almost 3 years ago (Acad Med. 2015 Feb;90[2]:221-30). It is the most recent follow-up (Devine et al. J Exp Soc Psychol. 2017 Nov;73:211-5) that corroborates that long-term changes are possible with intervention.

The published findings showed that when 1,137 faculty members from 46 departments in the experimental arm were compared with 1,153 faculty members from 46 departments in the control arm, there were significant improvements in the experimental arm in surveyed attitudes reflecting personal bias awareness (P = .001) and willingness to support gender equity (P = .013).

These changes in attitude translated into concrete changes in new female faculty hires in the most recent analysis. From 32% in a 2-year period before the workshops, the new female hires climbed to 46% in the 2-year period after the workshops – a relative increase of 44% in the departments participating in the experimental arm. In the control departments, female new faculty hires remained at 32% in both time periods.

“Basically, there are 20 new women faculty members at the University of Wisconsin because of this study,” Dr. Carnes said.

The training was not designed to change just male faculty perceptions but perceptions of both males and females. The result was a fundamental change in culture within departments randomized to the experimental arm, according to data generated by a variety of study analyses.

“When we looked at questions about department climate, we found that both male and female faculty members in the experimental groups were significantly more likely to say they fit in their department, they felt respected for their research and scholarship by their colleagues, and they felt comfortable raising personal and family issues even if they conflicted with departmental activities,” Dr. Carnes said.

This general attitude change is important, because Dr. Carnes emphasized that women share the cultural biases that can result in reduced female career opportunities in clinical and academic medicine. In addition, women generally are aware that stereotypical positive “agentic” adjectives for men, such as decisive, competitive, and ambitious, often are viewed negatively and generate backlash when applied to women. They therefore act on this awareness.

“Stereotype-based bias is a habit that can be broken, but it requires more than good intentions,” said Dr. Carnes, who emphasized that “gender-based assumptions and stereotypes are deeply embedded in the patterns of thinking of both men and women.”

As one example, Dr. Carnes cited her work evaluating female resident behavior when leading in-hospital code resuscitations. There are data to show that there is no difference in the effectiveness of male and female resident code leaders, but women typically feel that the assertive, aggressive behavior required for code leadership is “counternormative.” After the code, some women feel compelled to apologize to team members for being demanding or assertive, a step that Dr. Carnes attributed at least in part to fear of backlash from stepping out of gender-expected behavior.

The fix is not necessarily suppression of gender-related attributes. Dr. Carnes cited evidence that the stereotypical positive communal adjectives for women, such as nurturing, supportive, and sympathetic, might explain why studies suggest that women are more likely than men to be transformational leaders who inspire team members to contribute beyond their own self-interest in achieving goals.

Ultimately, the fix is replacement of stereotypes that impair men as well as women from defusing biases that “lead to subtle unintentional advantages in academic career advancement for Jack not afforded to Jill,” Dr. Carnes said. Based on the low numbers of female leaders in academic medicine decades after medical schools began enrolling women in substantial numbers, she concluded that meaningful change in gender bias is not likely to occur without implementation of specific proactive strategies aimed at challenging current perceptions. Her published study confirms that such strategies can help.

Dr. Carnes reported no conflicts of interest.

cpnews@frontlinemedcom.com

TAMPA, FLA. – Gender bias that disadvantages women from rising in academic medicine might require specific habit-changing strategies rather than efforts that draw on goodwill alone, according to new follow-up data from a randomized trial discussed and reevaluated at the annual meeting of the American College of Psychiatrists.

One premise of this trial, supported by other research, is that entrenched gender stereotypes drive both male and female behavior and must be addressed directly for change, said Molly Carnes, MD, professor of psychiatry at the University of Wisconsin, Madison.

The initial results of the trial, which randomized academic departments at the University of Wisconsin to participate in habit-changing workshops or to serve as controls, were published almost 3 years ago (Acad Med. 2015 Feb;90[2]:221-30). It is the most recent follow-up (Devine et al. J Exp Soc Psychol. 2017 Nov;73:211-5) that corroborates that long-term changes are possible with intervention.

The published findings showed that when 1,137 faculty members from 46 departments in the experimental arm were compared with 1,153 faculty members from 46 departments in the control arm, there were significant improvements in the experimental arm in surveyed attitudes reflecting personal bias awareness (P = .001) and willingness to support gender equity (P = .013).

These changes in attitude translated into concrete changes in new female faculty hires in the most recent analysis. From 32% in a 2-year period before the workshops, the new female hires climbed to 46% in the 2-year period after the workshops – a relative increase of 44% in the departments participating in the experimental arm. In the control departments, female new faculty hires remained at 32% in both time periods.

“Basically, there are 20 new women faculty members at the University of Wisconsin because of this study,” Dr. Carnes said.

The training was not designed to change just male faculty perceptions but perceptions of both males and females. The result was a fundamental change in culture within departments randomized to the experimental arm, according to data generated by a variety of study analyses.

“When we looked at questions about department climate, we found that both male and female faculty members in the experimental groups were significantly more likely to say they fit in their department, they felt respected for their research and scholarship by their colleagues, and they felt comfortable raising personal and family issues even if they conflicted with departmental activities,” Dr. Carnes said.

This general attitude change is important, because Dr. Carnes emphasized that women share the cultural biases that can result in reduced female career opportunities in clinical and academic medicine. In addition, women generally are aware that stereotypical positive “agentic” adjectives for men, such as decisive, competitive, and ambitious, often are viewed negatively and generate backlash when applied to women. They therefore act on this awareness.

“Stereotype-based bias is a habit that can be broken, but it requires more than good intentions,” said Dr. Carnes, who emphasized that “gender-based assumptions and stereotypes are deeply embedded in the patterns of thinking of both men and women.”

As one example, Dr. Carnes cited her work evaluating female resident behavior when leading in-hospital code resuscitations. There are data to show that there is no difference in the effectiveness of male and female resident code leaders, but women typically feel that the assertive, aggressive behavior required for code leadership is “counternormative.” After the code, some women feel compelled to apologize to team members for being demanding or assertive, a step that Dr. Carnes attributed at least in part to fear of backlash from stepping out of gender-expected behavior.

The fix is not necessarily suppression of gender-related attributes. Dr. Carnes cited evidence that the stereotypical positive communal adjectives for women, such as nurturing, supportive, and sympathetic, might explain why studies suggest that women are more likely than men to be transformational leaders who inspire team members to contribute beyond their own self-interest in achieving goals.

Ultimately, the fix is replacement of stereotypes that impair men as well as women from defusing biases that “lead to subtle unintentional advantages in academic career advancement for Jack not afforded to Jill,” Dr. Carnes said. Based on the low numbers of female leaders in academic medicine decades after medical schools began enrolling women in substantial numbers, she concluded that meaningful change in gender bias is not likely to occur without implementation of specific proactive strategies aimed at challenging current perceptions. Her published study confirms that such strategies can help.

Dr. Carnes reported no conflicts of interest.

cpnews@frontlinemedcom.com

Tranexamic acid is a synthetic lysine derivative that inhibits plasminogen activation by blocking lysine-binding sites on the plasminogen molecule. Although the US Food and Drug Administration–approved indications for tranexamic acid include treatment of patients with menorrhagia and reduction or prevention of hemorrhage in patients with hemophilia undergoing tooth extraction, the potential efficacy of tranexamic acid in the treatment of melasma has been consistently reported since the 1980s.¹

Tranexamic acid exerts effects on pigmentation via its inhibitory effects on UV light–induced plasminogen activator and plasmin activity.² UV radiation induces the synthesis of plasminogen activator by keratinocytes, which results in increased conversion of plasminogen to plasmin. Plasminogen activator induces tyrosinase activity, resulting in increased melanin synthesis. The presence of plasmin results in increased production of both arachidonic acid and fibroblast growth factor, which stimulate melanogenesis and neovascularization, respectively.³ By inhibiting plasminogen activation, tranexamic acid mitigates UV radiation–induced melanogenesis and neovascularization. In treated guinea pig skin, application of topical tranexamic acid following UV radiation exposure inhibited the development of expected skin hyperpigmentation and also reduced tyrosinase activity.^4,5

The largest study on the use of oral tranexamic acid for treatment of melasma was a retrospective chart review of 561 melasma patients treated with tranexamic acid at a single center in Singapore.⁶ More than 90% of patients received prior treatment of their melasma, including bleaching creams and energy-based treatment. Among patients who received oral tranexamic acid over a 4-month period, 90% of patients demonstrated improvement in their melasma severity. Side effects were experienced by 7% of patients; the most common side effects were abdominal bloating and pain (experienced by 2% of patients). Notably, 1 patient developed deep vein thrombosis during treatment and subsequently was found to have protein S deficiency.⁶

Although the daily doses of tranexamic acid for the treatment of menorrhagia and perioperative hemophilia patients are 3900 mg and 30 to 40 mg/kg, respectively, effective daily doses reported for the treatment of melasma have ranged from the initial report of efficacy at 750 to 1500 mg to subsequent reports of improvement at daily doses of 500 mg.^1,2,6-8

Challenges to the use of tranexamic acid for melasma treatment in the United States include the medicolegal environment, specifically the risks associated with using a systemic procoagulant medication for a cosmetic indication. Patients should be screened and counseled on the risks of developing deep vein thrombosis and pulmonary embolism prior to initiating treatment. Cost and accessibility also may limit the use of tranexamic acid in the United States. Tranexamic acid is available for off-label use in the United States with a prescription in the form of 650-mg tablets that can be split by patients to approximate twice-daily 325 mg dosing. This cosmetic indication poses an out-of-pocket cost to patients of over $110 per month or as low as $48 per month with a coupon at the time of publication.⁹

Given the potential for serious adverse effects with the use of systemic tranexamic acid, there has been interest in formulating and evaluating topical tranexamic acid for cosmetic indications.^10-13 Topical tranexamic acid has been used alone and in conjunction with modalities to increase uptake, including intradermal injection, microneedling, and fractionated CO₂ laser.^12-14 Although these reports show initial promise, the currently available data are limited by small sample sizes, short treatment durations, lack of dose comparisons, and lack of short-term or long-term follow-up data. In addition to addressing these knowledge gaps in our understanding of topical tranexamic acid as a treatment option for melasma, further studies on the minimum systemic dose may address the downside of cost and potential for complications that may limit use of this medication in the United States.

The potential uses for tranexamic acid extend to the treatment of postinflammatory hyperpigmentation and rosacea. Melanocytes cultured in media conditioned by fractionated CO₂ laser–treated keratinocytes were found to have decreased tyrosinase activity and reduced melanin content when treated with tranexamic acid, suggesting the potential role for tranexamic acid to be used postprocedurally to reduce the risk for postinflammatory hyperpigmentation in prone skin types.¹⁵ Oral and topical tranexamic acid also have been reported to improve the appearance of erythematotelangiectatic rosacea, potentially relating to the inhibitory effects of tranexamic acid on neovascularization.^3,16,17 Although larger-scale controlled studies are required for further investigation of tranexamic acid for these indications, it has shown early promise as an adjunctive treatment for several dermatologic disorders, including melasma, and warrants further characterization as a potential therapeutic option.

Tranexamic acid is a synthetic lysine derivative that inhibits plasminogen activation by blocking lysine-binding sites on the plasminogen molecule. Although the US Food and Drug Administration–approved indications for tranexamic acid include treatment of patients with menorrhagia and reduction or prevention of hemorrhage in patients with hemophilia undergoing tooth extraction, the potential efficacy of tranexamic acid in the treatment of melasma has been consistently reported since the 1980s.¹

Tranexamic acid exerts effects on pigmentation via its inhibitory effects on UV light–induced plasminogen activator and plasmin activity.² UV radiation induces the synthesis of plasminogen activator by keratinocytes, which results in increased conversion of plasminogen to plasmin. Plasminogen activator induces tyrosinase activity, resulting in increased melanin synthesis. The presence of plasmin results in increased production of both arachidonic acid and fibroblast growth factor, which stimulate melanogenesis and neovascularization, respectively.³ By inhibiting plasminogen activation, tranexamic acid mitigates UV radiation–induced melanogenesis and neovascularization. In treated guinea pig skin, application of topical tranexamic acid following UV radiation exposure inhibited the development of expected skin hyperpigmentation and also reduced tyrosinase activity.^4,5

The largest study on the use of oral tranexamic acid for treatment of melasma was a retrospective chart review of 561 melasma patients treated with tranexamic acid at a single center in Singapore.⁶ More than 90% of patients received prior treatment of their melasma, including bleaching creams and energy-based treatment. Among patients who received oral tranexamic acid over a 4-month period, 90% of patients demonstrated improvement in their melasma severity. Side effects were experienced by 7% of patients; the most common side effects were abdominal bloating and pain (experienced by 2% of patients). Notably, 1 patient developed deep vein thrombosis during treatment and subsequently was found to have protein S deficiency.⁶

Although the daily doses of tranexamic acid for the treatment of menorrhagia and perioperative hemophilia patients are 3900 mg and 30 to 40 mg/kg, respectively, effective daily doses reported for the treatment of melasma have ranged from the initial report of efficacy at 750 to 1500 mg to subsequent reports of improvement at daily doses of 500 mg.^1,2,6-8

Challenges to the use of tranexamic acid for melasma treatment in the United States include the medicolegal environment, specifically the risks associated with using a systemic procoagulant medication for a cosmetic indication. Patients should be screened and counseled on the risks of developing deep vein thrombosis and pulmonary embolism prior to initiating treatment. Cost and accessibility also may limit the use of tranexamic acid in the United States. Tranexamic acid is available for off-label use in the United States with a prescription in the form of 650-mg tablets that can be split by patients to approximate twice-daily 325 mg dosing. This cosmetic indication poses an out-of-pocket cost to patients of over $110 per month or as low as $48 per month with a coupon at the time of publication.⁹

Given the potential for serious adverse effects with the use of systemic tranexamic acid, there has been interest in formulating and evaluating topical tranexamic acid for cosmetic indications.^10-13 Topical tranexamic acid has been used alone and in conjunction with modalities to increase uptake, including intradermal injection, microneedling, and fractionated CO₂ laser.^12-14 Although these reports show initial promise, the currently available data are limited by small sample sizes, short treatment durations, lack of dose comparisons, and lack of short-term or long-term follow-up data. In addition to addressing these knowledge gaps in our understanding of topical tranexamic acid as a treatment option for melasma, further studies on the minimum systemic dose may address the downside of cost and potential for complications that may limit use of this medication in the United States.

The potential uses for tranexamic acid extend to the treatment of postinflammatory hyperpigmentation and rosacea. Melanocytes cultured in media conditioned by fractionated CO₂ laser–treated keratinocytes were found to have decreased tyrosinase activity and reduced melanin content when treated with tranexamic acid, suggesting the potential role for tranexamic acid to be used postprocedurally to reduce the risk for postinflammatory hyperpigmentation in prone skin types.¹⁵ Oral and topical tranexamic acid also have been reported to improve the appearance of erythematotelangiectatic rosacea, potentially relating to the inhibitory effects of tranexamic acid on neovascularization.^3,16,17 Although larger-scale controlled studies are required for further investigation of tranexamic acid for these indications, it has shown early promise as an adjunctive treatment for several dermatologic disorders, including melasma, and warrants further characterization as a potential therapeutic option.

Tranexamic acid is a synthetic lysine derivative that inhibits plasminogen activation by blocking lysine-binding sites on the plasminogen molecule. Although the US Food and Drug Administration–approved indications for tranexamic acid include treatment of patients with menorrhagia and reduction or prevention of hemorrhage in patients with hemophilia undergoing tooth extraction, the potential efficacy of tranexamic acid in the treatment of melasma has been consistently reported since the 1980s.¹

Tranexamic acid exerts effects on pigmentation via its inhibitory effects on UV light–induced plasminogen activator and plasmin activity.² UV radiation induces the synthesis of plasminogen activator by keratinocytes, which results in increased conversion of plasminogen to plasmin. Plasminogen activator induces tyrosinase activity, resulting in increased melanin synthesis. The presence of plasmin results in increased production of both arachidonic acid and fibroblast growth factor, which stimulate melanogenesis and neovascularization, respectively.³ By inhibiting plasminogen activation, tranexamic acid mitigates UV radiation–induced melanogenesis and neovascularization. In treated guinea pig skin, application of topical tranexamic acid following UV radiation exposure inhibited the development of expected skin hyperpigmentation and also reduced tyrosinase activity.^4,5

The largest study on the use of oral tranexamic acid for treatment of melasma was a retrospective chart review of 561 melasma patients treated with tranexamic acid at a single center in Singapore.⁶ More than 90% of patients received prior treatment of their melasma, including bleaching creams and energy-based treatment. Among patients who received oral tranexamic acid over a 4-month period, 90% of patients demonstrated improvement in their melasma severity. Side effects were experienced by 7% of patients; the most common side effects were abdominal bloating and pain (experienced by 2% of patients). Notably, 1 patient developed deep vein thrombosis during treatment and subsequently was found to have protein S deficiency.⁶

Although the daily doses of tranexamic acid for the treatment of menorrhagia and perioperative hemophilia patients are 3900 mg and 30 to 40 mg/kg, respectively, effective daily doses reported for the treatment of melasma have ranged from the initial report of efficacy at 750 to 1500 mg to subsequent reports of improvement at daily doses of 500 mg.^1,2,6-8

Challenges to the use of tranexamic acid for melasma treatment in the United States include the medicolegal environment, specifically the risks associated with using a systemic procoagulant medication for a cosmetic indication. Patients should be screened and counseled on the risks of developing deep vein thrombosis and pulmonary embolism prior to initiating treatment. Cost and accessibility also may limit the use of tranexamic acid in the United States. Tranexamic acid is available for off-label use in the United States with a prescription in the form of 650-mg tablets that can be split by patients to approximate twice-daily 325 mg dosing. This cosmetic indication poses an out-of-pocket cost to patients of over $110 per month or as low as $48 per month with a coupon at the time of publication.⁹

Given the potential for serious adverse effects with the use of systemic tranexamic acid, there has been interest in formulating and evaluating topical tranexamic acid for cosmetic indications.^10-13 Topical tranexamic acid has been used alone and in conjunction with modalities to increase uptake, including intradermal injection, microneedling, and fractionated CO₂ laser.^12-14 Although these reports show initial promise, the currently available data are limited by small sample sizes, short treatment durations, lack of dose comparisons, and lack of short-term or long-term follow-up data. In addition to addressing these knowledge gaps in our understanding of topical tranexamic acid as a treatment option for melasma, further studies on the minimum systemic dose may address the downside of cost and potential for complications that may limit use of this medication in the United States.

The potential uses for tranexamic acid extend to the treatment of postinflammatory hyperpigmentation and rosacea. Melanocytes cultured in media conditioned by fractionated CO₂ laser–treated keratinocytes were found to have decreased tyrosinase activity and reduced melanin content when treated with tranexamic acid, suggesting the potential role for tranexamic acid to be used postprocedurally to reduce the risk for postinflammatory hyperpigmentation in prone skin types.¹⁵ Oral and topical tranexamic acid also have been reported to improve the appearance of erythematotelangiectatic rosacea, potentially relating to the inhibitory effects of tranexamic acid on neovascularization.^3,16,17 Although larger-scale controlled studies are required for further investigation of tranexamic acid for these indications, it has shown early promise as an adjunctive treatment for several dermatologic disorders, including melasma, and warrants further characterization as a potential therapeutic option.

Question: Paramedics brought an unconscious 70-year-old man to a Florida hospital emergency department. The patient had the words “Do Not Resuscitate” tattooed onto his chest. No one accompanied him, and he had no identifications on his person. His blood alcohol level was elevated, and a few hours after his arrival, he lapsed into severe metabolic acidosis and hypotensive shock. The treating team decided to enter a DNR order, and the patient died shortly thereafter without benefit of cardiopulmonary resuscitation.

Which of the following is best?

A. An ethics consult may suggest honoring the patient’s DNR wishes, as it is reasonable to infer that the tattoo expressed an authentic preference.

B. It has been said, but remains debatable, that tattoos might represent “permanent reminders of regretted decisions made while the person was intoxicated.”

C. An earlier case report in the literature cautioned that the tattooed expression of a DNR request did not reflect that particular patient’s current wishes.

D. If this patient’s Florida Department of Health out-of-hospital DNR order confirms his DNR preference, then it is appropriate to withhold resuscitation.

E. All are correct.


ANSWER: E. The above hypothetical situation is modified from a recent case report in the correspondence section of the New England Journal of Medicine.¹ It can be read as offering a sharp and dramatic focus on the issue of consent surrounding decisions to withhold CPR.

In 1983, the President’s Commission for the Study of Ethical Problems in Medicine supported DNR protocols (“no code”) based on three value considerations: self-determination, well-being, and equity.²

Daisy-Daisy/Thinkstock

Dr. Tan is emeritus professor of medicine and a former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at siang@hawaii.edu.

References

1. N Engl J Med. 2017 Nov 30;377(22):2192-3.

2. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forego Life-Sustaining Treatment. Washington, DC: Government Printing Office, 1983.

3. J Gen Intern Med. 2011 Jul;26(7):791-7.

4. JAMA. 1995 Nov 22-29;274(20):1591-8.

5. Hawaii Med J. 2001 Mar;60(3):64-7.

6. N Engl J Med. 1997 Jun 26;336(26):1908-10.

7. Tan SY. Futility and DNR Orders. Internal Medicine News, March 21, 2014.

8. Gilgunn v. Mass. General Hosp. No. 92-4820 (Mass. Super Ct. Apr. 21, 1995).

9. In re Baby K, 16 F.3d 590 (4th Cir. 1994).

Question: Paramedics brought an unconscious 70-year-old man to a Florida hospital emergency department. The patient had the words “Do Not Resuscitate” tattooed onto his chest. No one accompanied him, and he had no identifications on his person. His blood alcohol level was elevated, and a few hours after his arrival, he lapsed into severe metabolic acidosis and hypotensive shock. The treating team decided to enter a DNR order, and the patient died shortly thereafter without benefit of cardiopulmonary resuscitation.

Which of the following is best?

A. An ethics consult may suggest honoring the patient’s DNR wishes, as it is reasonable to infer that the tattoo expressed an authentic preference.

B. It has been said, but remains debatable, that tattoos might represent “permanent reminders of regretted decisions made while the person was intoxicated.”

C. An earlier case report in the literature cautioned that the tattooed expression of a DNR request did not reflect that particular patient’s current wishes.

D. If this patient’s Florida Department of Health out-of-hospital DNR order confirms his DNR preference, then it is appropriate to withhold resuscitation.

E. All are correct.


ANSWER: E. The above hypothetical situation is modified from a recent case report in the correspondence section of the New England Journal of Medicine.¹ It can be read as offering a sharp and dramatic focus on the issue of consent surrounding decisions to withhold CPR.

In 1983, the President’s Commission for the Study of Ethical Problems in Medicine supported DNR protocols (“no code”) based on three value considerations: self-determination, well-being, and equity.²

Daisy-Daisy/Thinkstock

Dr. Tan is emeritus professor of medicine and a former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at siang@hawaii.edu.

References

1. N Engl J Med. 2017 Nov 30;377(22):2192-3.

2. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forego Life-Sustaining Treatment. Washington, DC: Government Printing Office, 1983.

3. J Gen Intern Med. 2011 Jul;26(7):791-7.

4. JAMA. 1995 Nov 22-29;274(20):1591-8.

5. Hawaii Med J. 2001 Mar;60(3):64-7.

6. N Engl J Med. 1997 Jun 26;336(26):1908-10.

7. Tan SY. Futility and DNR Orders. Internal Medicine News, March 21, 2014.

8. Gilgunn v. Mass. General Hosp. No. 92-4820 (Mass. Super Ct. Apr. 21, 1995).

9. In re Baby K, 16 F.3d 590 (4th Cir. 1994).

Question: Paramedics brought an unconscious 70-year-old man to a Florida hospital emergency department. The patient had the words “Do Not Resuscitate” tattooed onto his chest. No one accompanied him, and he had no identifications on his person. His blood alcohol level was elevated, and a few hours after his arrival, he lapsed into severe metabolic acidosis and hypotensive shock. The treating team decided to enter a DNR order, and the patient died shortly thereafter without benefit of cardiopulmonary resuscitation.

Which of the following is best?

A. An ethics consult may suggest honoring the patient’s DNR wishes, as it is reasonable to infer that the tattoo expressed an authentic preference.

B. It has been said, but remains debatable, that tattoos might represent “permanent reminders of regretted decisions made while the person was intoxicated.”

C. An earlier case report in the literature cautioned that the tattooed expression of a DNR request did not reflect that particular patient’s current wishes.

D. If this patient’s Florida Department of Health out-of-hospital DNR order confirms his DNR preference, then it is appropriate to withhold resuscitation.

E. All are correct.


ANSWER: E. The above hypothetical situation is modified from a recent case report in the correspondence section of the New England Journal of Medicine.¹ It can be read as offering a sharp and dramatic focus on the issue of consent surrounding decisions to withhold CPR.

In 1983, the President’s Commission for the Study of Ethical Problems in Medicine supported DNR protocols (“no code”) based on three value considerations: self-determination, well-being, and equity.²

Daisy-Daisy/Thinkstock

Dr. Tan is emeritus professor of medicine and a former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. For additional information, readers may contact the author at siang@hawaii.edu.

References

1. N Engl J Med. 2017 Nov 30;377(22):2192-3.

2. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forego Life-Sustaining Treatment. Washington, DC: Government Printing Office, 1983.

3. J Gen Intern Med. 2011 Jul;26(7):791-7.

4. JAMA. 1995 Nov 22-29;274(20):1591-8.

5. Hawaii Med J. 2001 Mar;60(3):64-7.

6. N Engl J Med. 1997 Jun 26;336(26):1908-10.

7. Tan SY. Futility and DNR Orders. Internal Medicine News, March 21, 2014.

8. Gilgunn v. Mass. General Hosp. No. 92-4820 (Mass. Super Ct. Apr. 21, 1995).

9. In re Baby K, 16 F.3d 590 (4th Cir. 1994).

Why are you bothering to read this? What could I offer that could possibly be useful to you? In fact, I was invited to write this column simply because I happened to be at the right conference at the right time. Soon, if not already, you’ll discover I’m actually not that clever. I’m an impostor.

I’ve thought this while staring at the blank page that is to be my article for the month. Reflecting on it, I realize you’ve probably had the same feelings of fraud at one time or another. Impostor syndrome is common. It is the experience of believing you don’t deserve a role or success despite evidence to the contrary. It often occurs at moments of transition, such as when you were accepted into medical school or matched into a competitive specialty. Looking at your peers, watching how your colleagues perform, you feel you just aren’t smart enough to be there; either someone made a mistake or you just got lucky.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@frontlinemedcom.com.

Why are you bothering to read this? What could I offer that could possibly be useful to you? In fact, I was invited to write this column simply because I happened to be at the right conference at the right time. Soon, if not already, you’ll discover I’m actually not that clever. I’m an impostor.

I’ve thought this while staring at the blank page that is to be my article for the month. Reflecting on it, I realize you’ve probably had the same feelings of fraud at one time or another. Impostor syndrome is common. It is the experience of believing you don’t deserve a role or success despite evidence to the contrary. It often occurs at moments of transition, such as when you were accepted into medical school or matched into a competitive specialty. Looking at your peers, watching how your colleagues perform, you feel you just aren’t smart enough to be there; either someone made a mistake or you just got lucky.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@frontlinemedcom.com.

Why are you bothering to read this? What could I offer that could possibly be useful to you? In fact, I was invited to write this column simply because I happened to be at the right conference at the right time. Soon, if not already, you’ll discover I’m actually not that clever. I’m an impostor.

I’ve thought this while staring at the blank page that is to be my article for the month. Reflecting on it, I realize you’ve probably had the same feelings of fraud at one time or another. Impostor syndrome is common. It is the experience of believing you don’t deserve a role or success despite evidence to the contrary. It often occurs at moments of transition, such as when you were accepted into medical school or matched into a competitive specialty. Looking at your peers, watching how your colleagues perform, you feel you just aren’t smart enough to be there; either someone made a mistake or you just got lucky.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@frontlinemedcom.com.

Case Presentation. A 23-year-old male U.S. Army veteran with a history of alcohol use disorder and posttraumatic stress disorder (PTSD) presented to the VA Boston Healthcare System (VABHS) West Roxbury campus emergency department (ED) with epigastric abdominal pain in the setting of consuming alcohol. The patient had served in the infantry in Afghanistan during Operation Enduring Freedom. He consumed up to 12 alcoholic drinks per day (both beer and hard liquor) for the past 3 years and had been hospitalized 3 times previously; twice for alcohol detoxification and once for PTSD. He is a former tobacco smoker with fewer than 5 pack-years, he uses marijuana often and does not use IV drugs. In the ED, his physical examination was notable for a heart rate of 130 beats per minute and blood pressure of 161/111 mm Hg. He was alert and oriented and had a mild tremor. The patient was diaphoretic with dry mucous membranes, tenderness to palpation in the epigastrium, and abdominal guarding. A computed tomography (CT) scan of the abdomen revealed acute pancreatitis without necrosis. The patient received 1 L of normal saline and was admitted to the medical ward for presumed alcoholic pancreatitis.

► Rahul Ganatra, MD, MPH, Chief Medical Resident, VABHS and Beth Israel Deaconess Medical Center. Dr. Weber, we care for many young people who drink more than they should and almost none of them end up with alcoholic pancreatitis. What are the relevant risk factors that make individuals like this patient more susceptible to alcoholic pancreatitis?

►Horst Christian Weber, MD, Gastroenterology Service, VABHS, and Assistant Professor of Medicine, Boston University School of Medicine. While we don’t have a good understanding of the precise mechanism of alcoholic pancreatitis, we do know that in the U.S., alcohol consumption is responsible for about one-third of all cases.¹ Acute pancreatitis in general may present with a wide range of disease severity. It is the most common cause of gastrointestinal-related hospitalization,² and the mortality of hospital inpatients with pancreatitis is about 5%.^3,4 Therefore, acute pancreatitis represents a prevalent condition with a critical impact on morbidity and mortality. Alcoholic pancreatitis typically occurs after many years of heavy alcohol use, not after a single drinking

► Dr. Ganatra. At this point, the chemistry laboratory paged the admitting resident with the notification that the patient’s blood was grossly lipemic. Ultracentrifugation was performed to separate the lipid layer and his laboratory values result (Table). Notable abnormalities included polycythemia with a hemoglobin of 17.4 g/dL, hyponatremia with a sodium of 129 mmol/L, normal renal function, elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (AST 258 IU/L and ALT 153 IU/L, respectively), hyperbilirubinemia with a total bilirubin of 2.7 mg/dL, and a serum alcohol level of 147 mg/dL. Due to anticipated requirement for a higher level of care, the patient was transferred to the Medical Intensive Care Unit (MICU).

Dr. Breu, can you help us interpret this patient’s numerous laboratory abnormalities? Without yet having the triglyceride level available, how does the fact that the patient’s blood was lipemic affect our interpretation of his labs? What further workup is warranted?

► Anthony Breu, MD, Medical Service, VABHS, Assistant Professor of Medicine, Harvard Medical School. First, the positive alcohol level confirms a recent ingestion. Second, he has elevated transaminases with the AST greater than the ALT, which is consistent with alcoholic liver disease. While the initial assumption is that this patient has alcohol-induced pancreatitis, the elevations in bilirubin and alkaline phosphatase may suggest gallstone pancreatitis, and the lipemic appearing serum could suggest triglyceride-mediated pancreatitis. If the patient does have elevated triglyceride levels, the sodium level may indicate pseudohyponatremia, a laboratory artifact seen if a dilution step is used. To further evaluate the patient, I would obtain a triglyceride level and a right upper quadrant ultrasound. Direct ion-selective electrode analysis of the sodium level can be done with a device used to measure blood gases to exclude pseudohyponatremia.

► Dr. Ganatra. A right upper quadrant ultrasound was obtained in the MICU, which showed hepatic steatosis and hepatomegaly to 19 cm, but no evidence of biliary obstruction by stones or sludge. The common bile duct measured 3.2 mm in diameter. A triglyceride level returned above assay at > 3,392 mg/dL. A review of the medical record revealed a triglyceride level of 105 mg/dL 16 months prior. The Gastroenterology Department was consulted.

Dr. Weber, we now have 2 etiologies for pancreatitis in this patient: alcohol and hypertriglyceridemia. How do each cause pancreatitis? Is it possible to determine in this case which one is the more likely driver?

► Dr. Weber. The mechanism for alcohol-induced pancreatitis is not fully known, but there are several hypotheses. One is that alcohol may increase the synthesis or activation of pancreatic digestive enzymes.⁶ Another is that metabolites of alcohol are directly toxic to the pancreas.⁶ Based on the epidemiologic observation that alcoholic pancreatitis usually happens in long-standing users, all we can say is that it is not very likely to be the effect of an acute insult. For hypertriglyceridemic pancreatitis, we believe the injury is due to the toxic effect of free fatty acids in the pancreas liberated by lipolysis of triglycerides by pancreatic lipases. Higher triglycerides are associated with higher risk, suggesting a dose-response relationship: This risk is not greatly increased until triglycerides exceed 500 mg/dL; above 1,000 mg/dL, the risk is about 5%, and above 2,000 mg/dL, the risk is between 10% and 20%.⁷ In summary, we cannot really determine whether the alcohol or the triglycerides are the main cause of his pancreatitis, but given his markedly elevated triglycerides, he should be treated for hypertriglyceridemic pancreatitis.

►Dr. Ganatra. Dr. Breu, regardless of the underlying etiology, this patient requires treatment. What does the literature suggest as the best course of action regarding crystalloid administration in patients with acute pancreatitis?

►Dr. Breu. There are 2 issues to discuss regarding IV fluids in acute pancreatitis: choice of crystalloid and rate of administration. For the choice of IV fluid, lactated Ringer solution (LR) may be preferred over normal saline (NS). There are both pathophysiologic and evidence-based rationales for this choice. As Dr. Weber alluded to, trypsinogen activation is an important step in the pathogenesis of acute pancreatitis and requires a low pH compartment. As most clinicians have experienced, NS may cause a metabolic acidosis; however, the use of LR may mitigate this. A 2011 randomized clinical trial showed that patients who received LR had less systemic inflammatory response syndrome (SIRS) and lower C-reactive protein (CRP) levels at 24 hours compared with patients who received NS.⁸ While these are surrogate outcomes, they, along with the theoretical basis, suggest LR is preferred.

Regarding rate, the key is fast and early.⁹ In my experience, internists often underdose IV rehydration within the first 12 to 24 hours, fail to change the rate based on clinical response, and leave patients on high rates too long. In a patient like this, a rate of 350 cc/h is a reasonable place to start. But, one must reassess response (ie, ensure there is a decrease in hematocrit and/or blood urea nitrogen) every 6 hours and increase the rate as needed. After the first 24 to 48 hours have passed, the rate should be lowered.

►Dr. Ganatra. The patient received 2 mg of IV hydromorphone and a 2 L bolus of LR. This was followed by a continuous infusion of LR at 200 cc/h. Dr. Weber, apart from the standard therapies for pancreatitis, what are our treatment options in hypertriglyceridemic pancreatitis?

►Dr. Weber. In the acute setting, IV insulin with or without dextrose is the most extensively studied therapy. Insulin rapidly decreases triglyceride levels by activating lipoprotein lipase and inhibiting hormone- sensitive lipase. The net effect is reduction in serum triglycerides available to be hydrolyzed to free fatty acids in the pancreas.⁷ For severe cases (ie, where acute pancreatitis is accompanied by hypocalcemia, lactic acidosis or a markedly elevated lipase), apheresis with therapeutic plasma exchange to more rapidly reduce triglyceride concentration is the preferred therapy. The goal is to reduce triglycerides to levels

►Dr. Ganatra. Due to the possibility that the patient would require apheresis, which was not available at the VABHS West Roxbury campus, the patient was transferred to an affiliate hospital. The patient was started on 10% dextrose at 300 cc/h and an IV insulin infusion. His triglycerides fell to < 500 mg/dL over the subsequent 48 hours, and ultimately, apheresis was not required. Enteral nutrition by nasogastric (NG) tube was initiated on hospital day 6. The patient’s hospital course was notable for acute respiratory distress syndrome that required intubation for 7 days, hyperbilirubinemia (with a peak bilirubin of 10.5 mg/dL), acute kidney injury (with a peak creatinine 4.7 mg/dL), fever without an identified infectious source, alcohol withdrawal syndrome that required phenobarbital, and delirium. Nine days later, he was transferred back to the VABHS West Roxbury campus. His condition stabilized, and he was transferred to the medical floor. On hospital day 14, the patient’s mental status improved, and he began tolerating oral nutrition.

Dr. Breu, over the years, the standard of care regarding when to start enteral nutrition in pancreatitis has changed considerably. This patient received enteral nutrition via NG tube but also had periods of being NPO (nothing by mouth) for up to 6 days. What is the current best practice for timing of initiating enteral nutrition in acute pancreatitis?

►Dr. Breu. It is true that the standard of care has changed and continues to evolve. Many decades ago, patients with acute pancreatitis would routinely undergo NG tube suction to reduce delivery of gastric contents to the duodenum, thereby decreasing pancreas activation, allowing it to rest.¹¹ The NG tube also allowed for decompression of any ileus that had formed. Beginning in the 1970s, several clinical trials were performed, showing that NG tube suction was no better than simply making the patient NPO.^12,13 More recently, we have begun to move toward earlier feeding. Again, there is a pathophysiologic rationale (bowel rest is associated with intestinal atrophy, predisposing to bacterial translocation and resulting infectious complications) and increasing evidence supporting this practice.⁹ Even in severe pancreatitis, hunger may be used to initiate oral intake.¹⁴

►Dr. Weber. Organ failure in the acute setting can occur due to activation of cytokine cascades and the systemic inflammatory response syndrome and is described by clinical and radiologic criteria called the Atlanta Classification.¹⁵ Apart from organ failure, the most serious complications of acute pancreatitis are necrosis of pancreatic tissue leading to walled-off pancreatic necrosis and the formation of peripancreatic fluid collections and pseudocysts, which occur in about 15% of patients with acute pancreatitis. These complications are serious because they can become infected, which portends a higher mortality and in some cases require surgical resection.

Other complications of acute pancreatitis include pseudoaneurysm formation, which is when a vessel bleeds into a pancreatic pseudocyst, and thromboses of the splenic, portal, or mesenteric veins. Thrombotic complications may occur in up to half of patients with pancreatic necrosis but are uncommon without some degree of necrosis.¹⁶ No necrosis was noted on this patient’s initial CT scan, so the probability of thrombosis is low. Also, as it takes several weeks for pseudocyst formation to occur, a bleeding pseudoaneurysm is unlikely at this early stage. Therefore, a complication of pancreatitis is unlikely in this patient, and evaluation for other causes of abdominal pain should be considered.

►Dr. Ganatra. A noncontrast CT of the abdomen and pelvis was obtained and revealed no evidence of complications or other acute pathology. His pain was managed conservatively, and hemoglobin remained stable. Over the next 5 days, the patient’s symptoms gradually resolved, his oral intake improved, and he was discharged home on gemfibrozil 600 mg twice daily 19 days after admission. He declined psychiatry follow-up for his PTSD, and after discharge he did not keep his scheduled gastroenterology (GI) follow-up appointment. Four months later, the patient presented again with epigastric abdominal pain similar to his initial presentation. The patient had resumed drinking, stating that “alcohol is the only thing that helps [with the PTSD].” He had not been taking the gemfibrozil. He was admitted with a recurrent episode of pancreatitis; however, his triglycerides on admission were 119 mg/dL.

Dr. Weber, this patient’s triglycerides declined rapidly over a period of just 4 months with questionable adherence to gemfibrozil. However, he was admitted again with another episode of pancreatitis, this time in the setting of alcohol use alone without markedly elevated triglycerides. What do we know about recurrence risk for pancreatitis? Are some etiologies of pancreatitis more likely to present with recurrent attacks than are others?

►Dr. Weber. The rate of recurrence following an episode of acute pancreatitis varies according to the cause, but in general, about 20% to 30% of patients will experience a recurrence, and 5% to 10% will go on to develop chronic pancreatitis.¹⁷ Alcoholic pancreatitis does carry a higher risk of recurrence than pancreatitis due to other causes; the risk is as high as 50%. Not surprisingly, recurrence of acute pancreatitis increases risk for development of chronic pancreatitis. As this patient is a smoker, it is worth noting that smoking potentiates pancreatic damage from alcohol and increases the risk for both recurrent and chronic pancreatitis.⁵

►Dr. Ganatra. The patient was treated with IV hydromorphone and IV LR at 350 cc/h. Oral nutrition was begun immediately. He manifested no organ dysfunction, and his symptoms improved over the course of 48 hours. He was discharged home with psychiatry and GI follow-up scheduled. Dr. Breu and Dr. Weber, how should we counsel this patient to reduce his risk of recurrent attacks of pancreatitis in the future, and what options do we have for pharmacotherapy to decrease his risk?

►Dr. Breu. I’ll let Dr. Weber comment on mitigating the risk of hypertriglyceride-induced pancreatitis and reserve my comments to pharmacotherapy in alcohol use disorder. This patient may be a candidate for naltrexone therapy, either in oral or intramuscular formulations. Both have been showed to reduce the risk of returning to heavy drinking and may be particularly beneficial in those with a family history.^18,19 Acamprosate is also an option.

►Dr. Weber. Data on recurrence risk in hypertriglyceridemic pancreatitis are limited, but there are case reports suggesting that a fatty diet and alcohol use are implicated in recurrence.²⁰ I would counsel the patient on lifestyle modifications that are known to reduce this risk. I agree with Dr. Breu that devoting our efforts to helping him reduce or eliminate his alcohol consumption is the single most important thing we can do to reduce his risk for recurrent attacks. Since the patient reports that he drinks alcohol in order to cope with his PTSD, establishing care with a mental health provider to address this is of the utmost importance. In addition, smoking cessation and promoting medication adherence with gemfibrozil will also reduce risk for future episodes, but continued alcohol use is his strongest risk factor.

►Dr. Ganatra. After discharge, the patient engaged with outpatient psychiatry and GI. He still reports feeling that alcohol is the only thing that alleviates his PTSD and anxiety symptoms. He is not currently interested in pharmacotherapy for cessation of alcohol use.

Acknowledgments
The authors thank Ivana Jankovic, MD, Matthew Lewis Chase, MD, Christopher Worsham, MD, Lakshmana Swamy, MD.

Case Presentation. A 23-year-old male U.S. Army veteran with a history of alcohol use disorder and posttraumatic stress disorder (PTSD) presented to the VA Boston Healthcare System (VABHS) West Roxbury campus emergency department (ED) with epigastric abdominal pain in the setting of consuming alcohol. The patient had served in the infantry in Afghanistan during Operation Enduring Freedom. He consumed up to 12 alcoholic drinks per day (both beer and hard liquor) for the past 3 years and had been hospitalized 3 times previously; twice for alcohol detoxification and once for PTSD. He is a former tobacco smoker with fewer than 5 pack-years, he uses marijuana often and does not use IV drugs. In the ED, his physical examination was notable for a heart rate of 130 beats per minute and blood pressure of 161/111 mm Hg. He was alert and oriented and had a mild tremor. The patient was diaphoretic with dry mucous membranes, tenderness to palpation in the epigastrium, and abdominal guarding. A computed tomography (CT) scan of the abdomen revealed acute pancreatitis without necrosis. The patient received 1 L of normal saline and was admitted to the medical ward for presumed alcoholic pancreatitis.

► Rahul Ganatra, MD, MPH, Chief Medical Resident, VABHS and Beth Israel Deaconess Medical Center. Dr. Weber, we care for many young people who drink more than they should and almost none of them end up with alcoholic pancreatitis. What are the relevant risk factors that make individuals like this patient more susceptible to alcoholic pancreatitis?

►Horst Christian Weber, MD, Gastroenterology Service, VABHS, and Assistant Professor of Medicine, Boston University School of Medicine. While we don’t have a good understanding of the precise mechanism of alcoholic pancreatitis, we do know that in the U.S., alcohol consumption is responsible for about one-third of all cases.¹ Acute pancreatitis in general may present with a wide range of disease severity. It is the most common cause of gastrointestinal-related hospitalization,² and the mortality of hospital inpatients with pancreatitis is about 5%.^3,4 Therefore, acute pancreatitis represents a prevalent condition with a critical impact on morbidity and mortality. Alcoholic pancreatitis typically occurs after many years of heavy alcohol use, not after a single drinking

► Dr. Ganatra. At this point, the chemistry laboratory paged the admitting resident with the notification that the patient’s blood was grossly lipemic. Ultracentrifugation was performed to separate the lipid layer and his laboratory values result (Table). Notable abnormalities included polycythemia with a hemoglobin of 17.4 g/dL, hyponatremia with a sodium of 129 mmol/L, normal renal function, elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (AST 258 IU/L and ALT 153 IU/L, respectively), hyperbilirubinemia with a total bilirubin of 2.7 mg/dL, and a serum alcohol level of 147 mg/dL. Due to anticipated requirement for a higher level of care, the patient was transferred to the Medical Intensive Care Unit (MICU).

Dr. Breu, can you help us interpret this patient’s numerous laboratory abnormalities? Without yet having the triglyceride level available, how does the fact that the patient’s blood was lipemic affect our interpretation of his labs? What further workup is warranted?

► Anthony Breu, MD, Medical Service, VABHS, Assistant Professor of Medicine, Harvard Medical School. First, the positive alcohol level confirms a recent ingestion. Second, he has elevated transaminases with the AST greater than the ALT, which is consistent with alcoholic liver disease. While the initial assumption is that this patient has alcohol-induced pancreatitis, the elevations in bilirubin and alkaline phosphatase may suggest gallstone pancreatitis, and the lipemic appearing serum could suggest triglyceride-mediated pancreatitis. If the patient does have elevated triglyceride levels, the sodium level may indicate pseudohyponatremia, a laboratory artifact seen if a dilution step is used. To further evaluate the patient, I would obtain a triglyceride level and a right upper quadrant ultrasound. Direct ion-selective electrode analysis of the sodium level can be done with a device used to measure blood gases to exclude pseudohyponatremia.

► Dr. Ganatra. A right upper quadrant ultrasound was obtained in the MICU, which showed hepatic steatosis and hepatomegaly to 19 cm, but no evidence of biliary obstruction by stones or sludge. The common bile duct measured 3.2 mm in diameter. A triglyceride level returned above assay at > 3,392 mg/dL. A review of the medical record revealed a triglyceride level of 105 mg/dL 16 months prior. The Gastroenterology Department was consulted.

Dr. Weber, we now have 2 etiologies for pancreatitis in this patient: alcohol and hypertriglyceridemia. How do each cause pancreatitis? Is it possible to determine in this case which one is the more likely driver?

► Dr. Weber. The mechanism for alcohol-induced pancreatitis is not fully known, but there are several hypotheses. One is that alcohol may increase the synthesis or activation of pancreatic digestive enzymes.⁶ Another is that metabolites of alcohol are directly toxic to the pancreas.⁶ Based on the epidemiologic observation that alcoholic pancreatitis usually happens in long-standing users, all we can say is that it is not very likely to be the effect of an acute insult. For hypertriglyceridemic pancreatitis, we believe the injury is due to the toxic effect of free fatty acids in the pancreas liberated by lipolysis of triglycerides by pancreatic lipases. Higher triglycerides are associated with higher risk, suggesting a dose-response relationship: This risk is not greatly increased until triglycerides exceed 500 mg/dL; above 1,000 mg/dL, the risk is about 5%, and above 2,000 mg/dL, the risk is between 10% and 20%.⁷ In summary, we cannot really determine whether the alcohol or the triglycerides are the main cause of his pancreatitis, but given his markedly elevated triglycerides, he should be treated for hypertriglyceridemic pancreatitis.

►Dr. Ganatra. Dr. Breu, regardless of the underlying etiology, this patient requires treatment. What does the literature suggest as the best course of action regarding crystalloid administration in patients with acute pancreatitis?

►Dr. Breu. There are 2 issues to discuss regarding IV fluids in acute pancreatitis: choice of crystalloid and rate of administration. For the choice of IV fluid, lactated Ringer solution (LR) may be preferred over normal saline (NS). There are both pathophysiologic and evidence-based rationales for this choice. As Dr. Weber alluded to, trypsinogen activation is an important step in the pathogenesis of acute pancreatitis and requires a low pH compartment. As most clinicians have experienced, NS may cause a metabolic acidosis; however, the use of LR may mitigate this. A 2011 randomized clinical trial showed that patients who received LR had less systemic inflammatory response syndrome (SIRS) and lower C-reactive protein (CRP) levels at 24 hours compared with patients who received NS.⁸ While these are surrogate outcomes, they, along with the theoretical basis, suggest LR is preferred.

Regarding rate, the key is fast and early.⁹ In my experience, internists often underdose IV rehydration within the first 12 to 24 hours, fail to change the rate based on clinical response, and leave patients on high rates too long. In a patient like this, a rate of 350 cc/h is a reasonable place to start. But, one must reassess response (ie, ensure there is a decrease in hematocrit and/or blood urea nitrogen) every 6 hours and increase the rate as needed. After the first 24 to 48 hours have passed, the rate should be lowered.

►Dr. Ganatra. The patient received 2 mg of IV hydromorphone and a 2 L bolus of LR. This was followed by a continuous infusion of LR at 200 cc/h. Dr. Weber, apart from the standard therapies for pancreatitis, what are our treatment options in hypertriglyceridemic pancreatitis?

►Dr. Weber. In the acute setting, IV insulin with or without dextrose is the most extensively studied therapy. Insulin rapidly decreases triglyceride levels by activating lipoprotein lipase and inhibiting hormone- sensitive lipase. The net effect is reduction in serum triglycerides available to be hydrolyzed to free fatty acids in the pancreas.⁷ For severe cases (ie, where acute pancreatitis is accompanied by hypocalcemia, lactic acidosis or a markedly elevated lipase), apheresis with therapeutic plasma exchange to more rapidly reduce triglyceride concentration is the preferred therapy. The goal is to reduce triglycerides to levels

►Dr. Ganatra. Due to the possibility that the patient would require apheresis, which was not available at the VABHS West Roxbury campus, the patient was transferred to an affiliate hospital. The patient was started on 10% dextrose at 300 cc/h and an IV insulin infusion. His triglycerides fell to < 500 mg/dL over the subsequent 48 hours, and ultimately, apheresis was not required. Enteral nutrition by nasogastric (NG) tube was initiated on hospital day 6. The patient’s hospital course was notable for acute respiratory distress syndrome that required intubation for 7 days, hyperbilirubinemia (with a peak bilirubin of 10.5 mg/dL), acute kidney injury (with a peak creatinine 4.7 mg/dL), fever without an identified infectious source, alcohol withdrawal syndrome that required phenobarbital, and delirium. Nine days later, he was transferred back to the VABHS West Roxbury campus. His condition stabilized, and he was transferred to the medical floor. On hospital day 14, the patient’s mental status improved, and he began tolerating oral nutrition.

Dr. Breu, over the years, the standard of care regarding when to start enteral nutrition in pancreatitis has changed considerably. This patient received enteral nutrition via NG tube but also had periods of being NPO (nothing by mouth) for up to 6 days. What is the current best practice for timing of initiating enteral nutrition in acute pancreatitis?

►Dr. Breu. It is true that the standard of care has changed and continues to evolve. Many decades ago, patients with acute pancreatitis would routinely undergo NG tube suction to reduce delivery of gastric contents to the duodenum, thereby decreasing pancreas activation, allowing it to rest.¹¹ The NG tube also allowed for decompression of any ileus that had formed. Beginning in the 1970s, several clinical trials were performed, showing that NG tube suction was no better than simply making the patient NPO.^12,13 More recently, we have begun to move toward earlier feeding. Again, there is a pathophysiologic rationale (bowel rest is associated with intestinal atrophy, predisposing to bacterial translocation and resulting infectious complications) and increasing evidence supporting this practice.⁹ Even in severe pancreatitis, hunger may be used to initiate oral intake.¹⁴

►Dr. Weber. Organ failure in the acute setting can occur due to activation of cytokine cascades and the systemic inflammatory response syndrome and is described by clinical and radiologic criteria called the Atlanta Classification.¹⁵ Apart from organ failure, the most serious complications of acute pancreatitis are necrosis of pancreatic tissue leading to walled-off pancreatic necrosis and the formation of peripancreatic fluid collections and pseudocysts, which occur in about 15% of patients with acute pancreatitis. These complications are serious because they can become infected, which portends a higher mortality and in some cases require surgical resection.

Other complications of acute pancreatitis include pseudoaneurysm formation, which is when a vessel bleeds into a pancreatic pseudocyst, and thromboses of the splenic, portal, or mesenteric veins. Thrombotic complications may occur in up to half of patients with pancreatic necrosis but are uncommon without some degree of necrosis.¹⁶ No necrosis was noted on this patient’s initial CT scan, so the probability of thrombosis is low. Also, as it takes several weeks for pseudocyst formation to occur, a bleeding pseudoaneurysm is unlikely at this early stage. Therefore, a complication of pancreatitis is unlikely in this patient, and evaluation for other causes of abdominal pain should be considered.

►Dr. Ganatra. A noncontrast CT of the abdomen and pelvis was obtained and revealed no evidence of complications or other acute pathology. His pain was managed conservatively, and hemoglobin remained stable. Over the next 5 days, the patient’s symptoms gradually resolved, his oral intake improved, and he was discharged home on gemfibrozil 600 mg twice daily 19 days after admission. He declined psychiatry follow-up for his PTSD, and after discharge he did not keep his scheduled gastroenterology (GI) follow-up appointment. Four months later, the patient presented again with epigastric abdominal pain similar to his initial presentation. The patient had resumed drinking, stating that “alcohol is the only thing that helps [with the PTSD].” He had not been taking the gemfibrozil. He was admitted with a recurrent episode of pancreatitis; however, his triglycerides on admission were 119 mg/dL.

Dr. Weber, this patient’s triglycerides declined rapidly over a period of just 4 months with questionable adherence to gemfibrozil. However, he was admitted again with another episode of pancreatitis, this time in the setting of alcohol use alone without markedly elevated triglycerides. What do we know about recurrence risk for pancreatitis? Are some etiologies of pancreatitis more likely to present with recurrent attacks than are others?

►Dr. Weber. The rate of recurrence following an episode of acute pancreatitis varies according to the cause, but in general, about 20% to 30% of patients will experience a recurrence, and 5% to 10% will go on to develop chronic pancreatitis.¹⁷ Alcoholic pancreatitis does carry a higher risk of recurrence than pancreatitis due to other causes; the risk is as high as 50%. Not surprisingly, recurrence of acute pancreatitis increases risk for development of chronic pancreatitis. As this patient is a smoker, it is worth noting that smoking potentiates pancreatic damage from alcohol and increases the risk for both recurrent and chronic pancreatitis.⁵

►Dr. Ganatra. The patient was treated with IV hydromorphone and IV LR at 350 cc/h. Oral nutrition was begun immediately. He manifested no organ dysfunction, and his symptoms improved over the course of 48 hours. He was discharged home with psychiatry and GI follow-up scheduled. Dr. Breu and Dr. Weber, how should we counsel this patient to reduce his risk of recurrent attacks of pancreatitis in the future, and what options do we have for pharmacotherapy to decrease his risk?

►Dr. Breu. I’ll let Dr. Weber comment on mitigating the risk of hypertriglyceride-induced pancreatitis and reserve my comments to pharmacotherapy in alcohol use disorder. This patient may be a candidate for naltrexone therapy, either in oral or intramuscular formulations. Both have been showed to reduce the risk of returning to heavy drinking and may be particularly beneficial in those with a family history.^18,19 Acamprosate is also an option.

►Dr. Weber. Data on recurrence risk in hypertriglyceridemic pancreatitis are limited, but there are case reports suggesting that a fatty diet and alcohol use are implicated in recurrence.²⁰ I would counsel the patient on lifestyle modifications that are known to reduce this risk. I agree with Dr. Breu that devoting our efforts to helping him reduce or eliminate his alcohol consumption is the single most important thing we can do to reduce his risk for recurrent attacks. Since the patient reports that he drinks alcohol in order to cope with his PTSD, establishing care with a mental health provider to address this is of the utmost importance. In addition, smoking cessation and promoting medication adherence with gemfibrozil will also reduce risk for future episodes, but continued alcohol use is his strongest risk factor.

►Dr. Ganatra. After discharge, the patient engaged with outpatient psychiatry and GI. He still reports feeling that alcohol is the only thing that alleviates his PTSD and anxiety symptoms. He is not currently interested in pharmacotherapy for cessation of alcohol use.

Acknowledgments
The authors thank Ivana Jankovic, MD, Matthew Lewis Chase, MD, Christopher Worsham, MD, Lakshmana Swamy, MD.

Case Presentation. A 23-year-old male U.S. Army veteran with a history of alcohol use disorder and posttraumatic stress disorder (PTSD) presented to the VA Boston Healthcare System (VABHS) West Roxbury campus emergency department (ED) with epigastric abdominal pain in the setting of consuming alcohol. The patient had served in the infantry in Afghanistan during Operation Enduring Freedom. He consumed up to 12 alcoholic drinks per day (both beer and hard liquor) for the past 3 years and had been hospitalized 3 times previously; twice for alcohol detoxification and once for PTSD. He is a former tobacco smoker with fewer than 5 pack-years, he uses marijuana often and does not use IV drugs. In the ED, his physical examination was notable for a heart rate of 130 beats per minute and blood pressure of 161/111 mm Hg. He was alert and oriented and had a mild tremor. The patient was diaphoretic with dry mucous membranes, tenderness to palpation in the epigastrium, and abdominal guarding. A computed tomography (CT) scan of the abdomen revealed acute pancreatitis without necrosis. The patient received 1 L of normal saline and was admitted to the medical ward for presumed alcoholic pancreatitis.

► Rahul Ganatra, MD, MPH, Chief Medical Resident, VABHS and Beth Israel Deaconess Medical Center. Dr. Weber, we care for many young people who drink more than they should and almost none of them end up with alcoholic pancreatitis. What are the relevant risk factors that make individuals like this patient more susceptible to alcoholic pancreatitis?

►Horst Christian Weber, MD, Gastroenterology Service, VABHS, and Assistant Professor of Medicine, Boston University School of Medicine. While we don’t have a good understanding of the precise mechanism of alcoholic pancreatitis, we do know that in the U.S., alcohol consumption is responsible for about one-third of all cases.¹ Acute pancreatitis in general may present with a wide range of disease severity. It is the most common cause of gastrointestinal-related hospitalization,² and the mortality of hospital inpatients with pancreatitis is about 5%.^3,4 Therefore, acute pancreatitis represents a prevalent condition with a critical impact on morbidity and mortality. Alcoholic pancreatitis typically occurs after many years of heavy alcohol use, not after a single drinking

► Dr. Ganatra. At this point, the chemistry laboratory paged the admitting resident with the notification that the patient’s blood was grossly lipemic. Ultracentrifugation was performed to separate the lipid layer and his laboratory values result (Table). Notable abnormalities included polycythemia with a hemoglobin of 17.4 g/dL, hyponatremia with a sodium of 129 mmol/L, normal renal function, elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (AST 258 IU/L and ALT 153 IU/L, respectively), hyperbilirubinemia with a total bilirubin of 2.7 mg/dL, and a serum alcohol level of 147 mg/dL. Due to anticipated requirement for a higher level of care, the patient was transferred to the Medical Intensive Care Unit (MICU).

Dr. Breu, can you help us interpret this patient’s numerous laboratory abnormalities? Without yet having the triglyceride level available, how does the fact that the patient’s blood was lipemic affect our interpretation of his labs? What further workup is warranted?

► Anthony Breu, MD, Medical Service, VABHS, Assistant Professor of Medicine, Harvard Medical School. First, the positive alcohol level confirms a recent ingestion. Second, he has elevated transaminases with the AST greater than the ALT, which is consistent with alcoholic liver disease. While the initial assumption is that this patient has alcohol-induced pancreatitis, the elevations in bilirubin and alkaline phosphatase may suggest gallstone pancreatitis, and the lipemic appearing serum could suggest triglyceride-mediated pancreatitis. If the patient does have elevated triglyceride levels, the sodium level may indicate pseudohyponatremia, a laboratory artifact seen if a dilution step is used. To further evaluate the patient, I would obtain a triglyceride level and a right upper quadrant ultrasound. Direct ion-selective electrode analysis of the sodium level can be done with a device used to measure blood gases to exclude pseudohyponatremia.

► Dr. Ganatra. A right upper quadrant ultrasound was obtained in the MICU, which showed hepatic steatosis and hepatomegaly to 19 cm, but no evidence of biliary obstruction by stones or sludge. The common bile duct measured 3.2 mm in diameter. A triglyceride level returned above assay at > 3,392 mg/dL. A review of the medical record revealed a triglyceride level of 105 mg/dL 16 months prior. The Gastroenterology Department was consulted.

Dr. Weber, we now have 2 etiologies for pancreatitis in this patient: alcohol and hypertriglyceridemia. How do each cause pancreatitis? Is it possible to determine in this case which one is the more likely driver?

► Dr. Weber. The mechanism for alcohol-induced pancreatitis is not fully known, but there are several hypotheses. One is that alcohol may increase the synthesis or activation of pancreatic digestive enzymes.⁶ Another is that metabolites of alcohol are directly toxic to the pancreas.⁶ Based on the epidemiologic observation that alcoholic pancreatitis usually happens in long-standing users, all we can say is that it is not very likely to be the effect of an acute insult. For hypertriglyceridemic pancreatitis, we believe the injury is due to the toxic effect of free fatty acids in the pancreas liberated by lipolysis of triglycerides by pancreatic lipases. Higher triglycerides are associated with higher risk, suggesting a dose-response relationship: This risk is not greatly increased until triglycerides exceed 500 mg/dL; above 1,000 mg/dL, the risk is about 5%, and above 2,000 mg/dL, the risk is between 10% and 20%.⁷ In summary, we cannot really determine whether the alcohol or the triglycerides are the main cause of his pancreatitis, but given his markedly elevated triglycerides, he should be treated for hypertriglyceridemic pancreatitis.

►Dr. Ganatra. Dr. Breu, regardless of the underlying etiology, this patient requires treatment. What does the literature suggest as the best course of action regarding crystalloid administration in patients with acute pancreatitis?

►Dr. Breu. There are 2 issues to discuss regarding IV fluids in acute pancreatitis: choice of crystalloid and rate of administration. For the choice of IV fluid, lactated Ringer solution (LR) may be preferred over normal saline (NS). There are both pathophysiologic and evidence-based rationales for this choice. As Dr. Weber alluded to, trypsinogen activation is an important step in the pathogenesis of acute pancreatitis and requires a low pH compartment. As most clinicians have experienced, NS may cause a metabolic acidosis; however, the use of LR may mitigate this. A 2011 randomized clinical trial showed that patients who received LR had less systemic inflammatory response syndrome (SIRS) and lower C-reactive protein (CRP) levels at 24 hours compared with patients who received NS.⁸ While these are surrogate outcomes, they, along with the theoretical basis, suggest LR is preferred.

Regarding rate, the key is fast and early.⁹ In my experience, internists often underdose IV rehydration within the first 12 to 24 hours, fail to change the rate based on clinical response, and leave patients on high rates too long. In a patient like this, a rate of 350 cc/h is a reasonable place to start. But, one must reassess response (ie, ensure there is a decrease in hematocrit and/or blood urea nitrogen) every 6 hours and increase the rate as needed. After the first 24 to 48 hours have passed, the rate should be lowered.

►Dr. Ganatra. The patient received 2 mg of IV hydromorphone and a 2 L bolus of LR. This was followed by a continuous infusion of LR at 200 cc/h. Dr. Weber, apart from the standard therapies for pancreatitis, what are our treatment options in hypertriglyceridemic pancreatitis?

►Dr. Weber. In the acute setting, IV insulin with or without dextrose is the most extensively studied therapy. Insulin rapidly decreases triglyceride levels by activating lipoprotein lipase and inhibiting hormone- sensitive lipase. The net effect is reduction in serum triglycerides available to be hydrolyzed to free fatty acids in the pancreas.⁷ For severe cases (ie, where acute pancreatitis is accompanied by hypocalcemia, lactic acidosis or a markedly elevated lipase), apheresis with therapeutic plasma exchange to more rapidly reduce triglyceride concentration is the preferred therapy. The goal is to reduce triglycerides to levels

►Dr. Ganatra. Due to the possibility that the patient would require apheresis, which was not available at the VABHS West Roxbury campus, the patient was transferred to an affiliate hospital. The patient was started on 10% dextrose at 300 cc/h and an IV insulin infusion. His triglycerides fell to < 500 mg/dL over the subsequent 48 hours, and ultimately, apheresis was not required. Enteral nutrition by nasogastric (NG) tube was initiated on hospital day 6. The patient’s hospital course was notable for acute respiratory distress syndrome that required intubation for 7 days, hyperbilirubinemia (with a peak bilirubin of 10.5 mg/dL), acute kidney injury (with a peak creatinine 4.7 mg/dL), fever without an identified infectious source, alcohol withdrawal syndrome that required phenobarbital, and delirium. Nine days later, he was transferred back to the VABHS West Roxbury campus. His condition stabilized, and he was transferred to the medical floor. On hospital day 14, the patient’s mental status improved, and he began tolerating oral nutrition.

Dr. Breu, over the years, the standard of care regarding when to start enteral nutrition in pancreatitis has changed considerably. This patient received enteral nutrition via NG tube but also had periods of being NPO (nothing by mouth) for up to 6 days. What is the current best practice for timing of initiating enteral nutrition in acute pancreatitis?

►Dr. Breu. It is true that the standard of care has changed and continues to evolve. Many decades ago, patients with acute pancreatitis would routinely undergo NG tube suction to reduce delivery of gastric contents to the duodenum, thereby decreasing pancreas activation, allowing it to rest.¹¹ The NG tube also allowed for decompression of any ileus that had formed. Beginning in the 1970s, several clinical trials were performed, showing that NG tube suction was no better than simply making the patient NPO.^12,13 More recently, we have begun to move toward earlier feeding. Again, there is a pathophysiologic rationale (bowel rest is associated with intestinal atrophy, predisposing to bacterial translocation and resulting infectious complications) and increasing evidence supporting this practice.⁹ Even in severe pancreatitis, hunger may be used to initiate oral intake.¹⁴

►Dr. Weber. Organ failure in the acute setting can occur due to activation of cytokine cascades and the systemic inflammatory response syndrome and is described by clinical and radiologic criteria called the Atlanta Classification.¹⁵ Apart from organ failure, the most serious complications of acute pancreatitis are necrosis of pancreatic tissue leading to walled-off pancreatic necrosis and the formation of peripancreatic fluid collections and pseudocysts, which occur in about 15% of patients with acute pancreatitis. These complications are serious because they can become infected, which portends a higher mortality and in some cases require surgical resection.

Other complications of acute pancreatitis include pseudoaneurysm formation, which is when a vessel bleeds into a pancreatic pseudocyst, and thromboses of the splenic, portal, or mesenteric veins. Thrombotic complications may occur in up to half of patients with pancreatic necrosis but are uncommon without some degree of necrosis.¹⁶ No necrosis was noted on this patient’s initial CT scan, so the probability of thrombosis is low. Also, as it takes several weeks for pseudocyst formation to occur, a bleeding pseudoaneurysm is unlikely at this early stage. Therefore, a complication of pancreatitis is unlikely in this patient, and evaluation for other causes of abdominal pain should be considered.

►Dr. Ganatra. A noncontrast CT of the abdomen and pelvis was obtained and revealed no evidence of complications or other acute pathology. His pain was managed conservatively, and hemoglobin remained stable. Over the next 5 days, the patient’s symptoms gradually resolved, his oral intake improved, and he was discharged home on gemfibrozil 600 mg twice daily 19 days after admission. He declined psychiatry follow-up for his PTSD, and after discharge he did not keep his scheduled gastroenterology (GI) follow-up appointment. Four months later, the patient presented again with epigastric abdominal pain similar to his initial presentation. The patient had resumed drinking, stating that “alcohol is the only thing that helps [with the PTSD].” He had not been taking the gemfibrozil. He was admitted with a recurrent episode of pancreatitis; however, his triglycerides on admission were 119 mg/dL.

Dr. Weber, this patient’s triglycerides declined rapidly over a period of just 4 months with questionable adherence to gemfibrozil. However, he was admitted again with another episode of pancreatitis, this time in the setting of alcohol use alone without markedly elevated triglycerides. What do we know about recurrence risk for pancreatitis? Are some etiologies of pancreatitis more likely to present with recurrent attacks than are others?

►Dr. Weber. The rate of recurrence following an episode of acute pancreatitis varies according to the cause, but in general, about 20% to 30% of patients will experience a recurrence, and 5% to 10% will go on to develop chronic pancreatitis.¹⁷ Alcoholic pancreatitis does carry a higher risk of recurrence than pancreatitis due to other causes; the risk is as high as 50%. Not surprisingly, recurrence of acute pancreatitis increases risk for development of chronic pancreatitis. As this patient is a smoker, it is worth noting that smoking potentiates pancreatic damage from alcohol and increases the risk for both recurrent and chronic pancreatitis.⁵

►Dr. Ganatra. The patient was treated with IV hydromorphone and IV LR at 350 cc/h. Oral nutrition was begun immediately. He manifested no organ dysfunction, and his symptoms improved over the course of 48 hours. He was discharged home with psychiatry and GI follow-up scheduled. Dr. Breu and Dr. Weber, how should we counsel this patient to reduce his risk of recurrent attacks of pancreatitis in the future, and what options do we have for pharmacotherapy to decrease his risk?

►Dr. Breu. I’ll let Dr. Weber comment on mitigating the risk of hypertriglyceride-induced pancreatitis and reserve my comments to pharmacotherapy in alcohol use disorder. This patient may be a candidate for naltrexone therapy, either in oral or intramuscular formulations. Both have been showed to reduce the risk of returning to heavy drinking and may be particularly beneficial in those with a family history.^18,19 Acamprosate is also an option.

►Dr. Weber. Data on recurrence risk in hypertriglyceridemic pancreatitis are limited, but there are case reports suggesting that a fatty diet and alcohol use are implicated in recurrence.²⁰ I would counsel the patient on lifestyle modifications that are known to reduce this risk. I agree with Dr. Breu that devoting our efforts to helping him reduce or eliminate his alcohol consumption is the single most important thing we can do to reduce his risk for recurrent attacks. Since the patient reports that he drinks alcohol in order to cope with his PTSD, establishing care with a mental health provider to address this is of the utmost importance. In addition, smoking cessation and promoting medication adherence with gemfibrozil will also reduce risk for future episodes, but continued alcohol use is his strongest risk factor.

►Dr. Ganatra. After discharge, the patient engaged with outpatient psychiatry and GI. He still reports feeling that alcohol is the only thing that alleviates his PTSD and anxiety symptoms. He is not currently interested in pharmacotherapy for cessation of alcohol use.

Acknowledgments
The authors thank Ivana Jankovic, MD, Matthew Lewis Chase, MD, Christopher Worsham, MD, Lakshmana Swamy, MD.

KAUAI, HAWAII – Two keys to effective topical treatment of onychomycosis are treat it early and address coexisting tinea pedis, according to Theodore Rosen, MD.

A third element in achieving treatment success is to use one of the newer topical agents: efinaconazole (Jublia) or tavaborole (Kerydin). The efficacy of efinaconazole approaches that of terbinafine, the most effective and widely prescribed oral agent, which has a 59% rate of almost complete cure, defined as less than 10% residual abnormal nail with no requirement for mycologic cure.

Bruce Jancin/Frontline Medical News

And while tavaborole isn’t quite as effective, it’s definitely better than previous topical agents, Dr. Rosen said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Both of these topicals are well tolerated and feature good nail permeation. They also allow for spread to the lateral nail folds and hyponychium. They even penetrate nail polish, although efinaconazole often causes the polish to lose its spiffy gloss, said Dr. Rosen, professor of dermatology at Baylor College of Medicine, Houston.

To underscore the importance of early treatment and addressing concomitant tinea pedis, he cited published secondary analyses of two identical double-blind, multicenter, 48-week clinical trials totaling 1,655 adults with onychomycosis who were randomized 3:1 to once-daily efinaconazole 10% topical solution or its vehicle.
 

Treat early

Phoebe Rich, MD, of the Oregon Dermatology and Research Center, Portland, broke down the outcomes according to disease duration, in a study of more than 1,500 patients with onychomycosis. She found that the complete cure rate at 52 weeks dropped off markedly in patients with a history of onychomycosis for 1 year or longer at baseline.

Complete cure – defined as no clinical involvement of the target toenail along with both a negative potassium hydroxide examination and a negative fungal culture at 52 weeks – was achieved in 43% of efinaconazole-treated patients with onychomycosis for less than 1 year. The rate then plunged to 17% in those with a disease duration of 1-5 years and 16% in patients with onychomycosis for more than 5 years. Nevertheless, the topical antifungal was significantly more effective than was the vehicle, across the board, with complete cure rates in the vehicle group of roughly 18%, 5%, and 2%, respectively, in patients with onychomycosis for less than 1 year, 1-5 years, and more than 5 years (J Drugs Dermatol. 2015 Jan;14[1]:58-62).
 

Tackle coexisting tinea pedis

Podiatrists analyzed the combined efinaconazole outcome data based on whether participants had no coexisting tinea pedis, baseline tinea pedis treated concomitantly with an investigator-approved topical antifungal, or tinea pedis left untreated. They concluded that treatment of coexisting tinea pedis decisively enhanced the efficacy of efinaconazole for onychomycosis.

A total of 21% of study participants had concomitant tinea pedis, and 61% of them were treated for it. At week 52, the onychomycosis complete cure rate was 29% in the efinaconazole group concurrently treated for tinea pedis, compared with just 16% if their tinea pedis was untreated (J Am Podiatr Med Assoc. 2015 Sep;105[5]:407-11).

“If you see tinea pedis, don’t blow it off. Treat it. Otherwise, you’re not getting rid of the fungal reservoir,” Dr. Rosen emphasized.

He noted that two topical agents approved for tinea pedis – naftifine 2% cream or gel and luliconazole 1% cream – are effective as once-daily therapy for 2 weeks, a considerably briefer regimen than with other approved topicals. And short-course therapy spells improved adherence, he added.

In the pivotal trials, naftifine had an effective treatment rate – a clinically useful endpoint defined as a small amount of residual scaling and/or redness but no itching – of 57%, while for luliconazole the rates were 33%-48%.

These two agents also are approved for treatment of tinea corporis and tinea cruris. Naftifine is approved as a once-daily treatment for 2 weeks, while luliconazole is, notably, a 7-day treatment. Luliconazole, in particular, is a relatively expensive drug, Dr. Rosen added, so insurers may require prior failure on clotrimazole.
 

When to treat onychomycosis topically

The pivotal trials of tavaborole and efinaconazole were conducted in patients with 20%-60% nail involvement. The infection didn’t extend to the matrix, and nail thickness and crumbly subungual debris were modest at baseline.

“There are always potential safety issues – drug interactions, GI disturbance, taste loss, headache, teratogenicity, cardiotoxicity, hepatotoxicity – anytime you put a pill in your mouth. So if you have a patient who’s dedicated enough to use a topical for 48 weeks and it’s a modestly affected nail, think about it,” Dr. Rosen advised.

He reported serving on scientific advisory boards for Aclaris, Anacor, Cipla, and Valeant.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
 

bjancin@frontlinemedcom.com

KAUAI, HAWAII – Two keys to effective topical treatment of onychomycosis are treat it early and address coexisting tinea pedis, according to Theodore Rosen, MD.

A third element in achieving treatment success is to use one of the newer topical agents: efinaconazole (Jublia) or tavaborole (Kerydin). The efficacy of efinaconazole approaches that of terbinafine, the most effective and widely prescribed oral agent, which has a 59% rate of almost complete cure, defined as less than 10% residual abnormal nail with no requirement for mycologic cure.

Bruce Jancin/Frontline Medical News

And while tavaborole isn’t quite as effective, it’s definitely better than previous topical agents, Dr. Rosen said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Both of these topicals are well tolerated and feature good nail permeation. They also allow for spread to the lateral nail folds and hyponychium. They even penetrate nail polish, although efinaconazole often causes the polish to lose its spiffy gloss, said Dr. Rosen, professor of dermatology at Baylor College of Medicine, Houston.

To underscore the importance of early treatment and addressing concomitant tinea pedis, he cited published secondary analyses of two identical double-blind, multicenter, 48-week clinical trials totaling 1,655 adults with onychomycosis who were randomized 3:1 to once-daily efinaconazole 10% topical solution or its vehicle.
 

Treat early

Phoebe Rich, MD, of the Oregon Dermatology and Research Center, Portland, broke down the outcomes according to disease duration, in a study of more than 1,500 patients with onychomycosis. She found that the complete cure rate at 52 weeks dropped off markedly in patients with a history of onychomycosis for 1 year or longer at baseline.

Complete cure – defined as no clinical involvement of the target toenail along with both a negative potassium hydroxide examination and a negative fungal culture at 52 weeks – was achieved in 43% of efinaconazole-treated patients with onychomycosis for less than 1 year. The rate then plunged to 17% in those with a disease duration of 1-5 years and 16% in patients with onychomycosis for more than 5 years. Nevertheless, the topical antifungal was significantly more effective than was the vehicle, across the board, with complete cure rates in the vehicle group of roughly 18%, 5%, and 2%, respectively, in patients with onychomycosis for less than 1 year, 1-5 years, and more than 5 years (J Drugs Dermatol. 2015 Jan;14[1]:58-62).
 

Tackle coexisting tinea pedis

Podiatrists analyzed the combined efinaconazole outcome data based on whether participants had no coexisting tinea pedis, baseline tinea pedis treated concomitantly with an investigator-approved topical antifungal, or tinea pedis left untreated. They concluded that treatment of coexisting tinea pedis decisively enhanced the efficacy of efinaconazole for onychomycosis.

A total of 21% of study participants had concomitant tinea pedis, and 61% of them were treated for it. At week 52, the onychomycosis complete cure rate was 29% in the efinaconazole group concurrently treated for tinea pedis, compared with just 16% if their tinea pedis was untreated (J Am Podiatr Med Assoc. 2015 Sep;105[5]:407-11).

“If you see tinea pedis, don’t blow it off. Treat it. Otherwise, you’re not getting rid of the fungal reservoir,” Dr. Rosen emphasized.

He noted that two topical agents approved for tinea pedis – naftifine 2% cream or gel and luliconazole 1% cream – are effective as once-daily therapy for 2 weeks, a considerably briefer regimen than with other approved topicals. And short-course therapy spells improved adherence, he added.

In the pivotal trials, naftifine had an effective treatment rate – a clinically useful endpoint defined as a small amount of residual scaling and/or redness but no itching – of 57%, while for luliconazole the rates were 33%-48%.

These two agents also are approved for treatment of tinea corporis and tinea cruris. Naftifine is approved as a once-daily treatment for 2 weeks, while luliconazole is, notably, a 7-day treatment. Luliconazole, in particular, is a relatively expensive drug, Dr. Rosen added, so insurers may require prior failure on clotrimazole.
 

When to treat onychomycosis topically

The pivotal trials of tavaborole and efinaconazole were conducted in patients with 20%-60% nail involvement. The infection didn’t extend to the matrix, and nail thickness and crumbly subungual debris were modest at baseline.

“There are always potential safety issues – drug interactions, GI disturbance, taste loss, headache, teratogenicity, cardiotoxicity, hepatotoxicity – anytime you put a pill in your mouth. So if you have a patient who’s dedicated enough to use a topical for 48 weeks and it’s a modestly affected nail, think about it,” Dr. Rosen advised.

He reported serving on scientific advisory boards for Aclaris, Anacor, Cipla, and Valeant.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
 

bjancin@frontlinemedcom.com

KAUAI, HAWAII – Two keys to effective topical treatment of onychomycosis are treat it early and address coexisting tinea pedis, according to Theodore Rosen, MD.

A third element in achieving treatment success is to use one of the newer topical agents: efinaconazole (Jublia) or tavaborole (Kerydin). The efficacy of efinaconazole approaches that of terbinafine, the most effective and widely prescribed oral agent, which has a 59% rate of almost complete cure, defined as less than 10% residual abnormal nail with no requirement for mycologic cure.

Bruce Jancin/Frontline Medical News

And while tavaborole isn’t quite as effective, it’s definitely better than previous topical agents, Dr. Rosen said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Both of these topicals are well tolerated and feature good nail permeation. They also allow for spread to the lateral nail folds and hyponychium. They even penetrate nail polish, although efinaconazole often causes the polish to lose its spiffy gloss, said Dr. Rosen, professor of dermatology at Baylor College of Medicine, Houston.

To underscore the importance of early treatment and addressing concomitant tinea pedis, he cited published secondary analyses of two identical double-blind, multicenter, 48-week clinical trials totaling 1,655 adults with onychomycosis who were randomized 3:1 to once-daily efinaconazole 10% topical solution or its vehicle.
 

Treat early

Phoebe Rich, MD, of the Oregon Dermatology and Research Center, Portland, broke down the outcomes according to disease duration, in a study of more than 1,500 patients with onychomycosis. She found that the complete cure rate at 52 weeks dropped off markedly in patients with a history of onychomycosis for 1 year or longer at baseline.

Complete cure – defined as no clinical involvement of the target toenail along with both a negative potassium hydroxide examination and a negative fungal culture at 52 weeks – was achieved in 43% of efinaconazole-treated patients with onychomycosis for less than 1 year. The rate then plunged to 17% in those with a disease duration of 1-5 years and 16% in patients with onychomycosis for more than 5 years. Nevertheless, the topical antifungal was significantly more effective than was the vehicle, across the board, with complete cure rates in the vehicle group of roughly 18%, 5%, and 2%, respectively, in patients with onychomycosis for less than 1 year, 1-5 years, and more than 5 years (J Drugs Dermatol. 2015 Jan;14[1]:58-62).
 

Tackle coexisting tinea pedis

Podiatrists analyzed the combined efinaconazole outcome data based on whether participants had no coexisting tinea pedis, baseline tinea pedis treated concomitantly with an investigator-approved topical antifungal, or tinea pedis left untreated. They concluded that treatment of coexisting tinea pedis decisively enhanced the efficacy of efinaconazole for onychomycosis.

A total of 21% of study participants had concomitant tinea pedis, and 61% of them were treated for it. At week 52, the onychomycosis complete cure rate was 29% in the efinaconazole group concurrently treated for tinea pedis, compared with just 16% if their tinea pedis was untreated (J Am Podiatr Med Assoc. 2015 Sep;105[5]:407-11).

“If you see tinea pedis, don’t blow it off. Treat it. Otherwise, you’re not getting rid of the fungal reservoir,” Dr. Rosen emphasized.

He noted that two topical agents approved for tinea pedis – naftifine 2% cream or gel and luliconazole 1% cream – are effective as once-daily therapy for 2 weeks, a considerably briefer regimen than with other approved topicals. And short-course therapy spells improved adherence, he added.

In the pivotal trials, naftifine had an effective treatment rate – a clinically useful endpoint defined as a small amount of residual scaling and/or redness but no itching – of 57%, while for luliconazole the rates were 33%-48%.

These two agents also are approved for treatment of tinea corporis and tinea cruris. Naftifine is approved as a once-daily treatment for 2 weeks, while luliconazole is, notably, a 7-day treatment. Luliconazole, in particular, is a relatively expensive drug, Dr. Rosen added, so insurers may require prior failure on clotrimazole.
 

When to treat onychomycosis topically

The pivotal trials of tavaborole and efinaconazole were conducted in patients with 20%-60% nail involvement. The infection didn’t extend to the matrix, and nail thickness and crumbly subungual debris were modest at baseline.

“There are always potential safety issues – drug interactions, GI disturbance, taste loss, headache, teratogenicity, cardiotoxicity, hepatotoxicity – anytime you put a pill in your mouth. So if you have a patient who’s dedicated enough to use a topical for 48 weeks and it’s a modestly affected nail, think about it,” Dr. Rosen advised.

He reported serving on scientific advisory boards for Aclaris, Anacor, Cipla, and Valeant.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
 

bjancin@frontlinemedcom.com

Rankings of US residency programs based on academic achievement are a resource for fourth-year medical students applying for residency through the National Resident Matching Program. They also highlight the leading academic training programs in each medical specialty. Currently, the Doximity Residency Navigator (https://residency.doximity.com) provides rankings of US residency programs based on either subjective or objective criteria. The subjective rankings utilize current resident and recent alumni satisfaction surveys as well as nominations from board-certified Doximity members who were asked to nominate up to 5 residency programs in their specialty that offer the best clinical training. The objective rankings are based on measurement of research output, which is calculated from the collective h-index of publications authored by graduating alumni within the last 15 years as well as the amount of research funding awarded.¹

Aquino et al² provided a ranking of US dermatology residency programs using alternative objective data measures (as of December 31, 2008) from the Doximity algorithm, including National Institutes of Health (NIH) and Dermatology Foundation (DF) funding, number of publications by full-time faculty members, number of faculty lectures given at annual meetings of 5 societies, and number of full-time faculty members serving on the editorial boards of 6 dermatology journals. The current study is an update to those rankings utilizing data from 2014.

Methods

The following data for each dermatology residency program were obtained to formulate the rankings: number of full-time faculty members, amount of NIH funding received in 2014 (https://report.nih.gov/), number of publications by full-time faculty members in 2014 (http://www.ncbi.nlm.nih.gov/pubmed/), and the number of faculty lectures given at annual meetings of 5 societies in 2014 (American Academy of Dermatology, the Society for Investigative Dermatology, the American Society of Dermatopathology, the Society for Pediatric Dermatology, and the American Society for Dermatologic Surgery). This study was approved by the institutional review board at Kaiser Permanente Southern California.

The names of all US dermatology residency programs were obtained as of December 31, 2014, from FREIDA Online using the search term dermatology. An email was sent to a representative from each residency program (eg, residency program coordinator, program director, full-time faculty member) requesting confirmation of a list of full-time faculty members in the program, excluding part-time and volunteer faculty. If a response was not obtained or the representative declined to participate, a list was compiled using available information from that residency program’s website.

National Institutes of Health funding for 2014 was obtained for individual faculty members from the NIH Research Portfolio Online Reporting Tools expenditures and reports (https://projectreporter.nih.gov/reporter.cfm) by searching the first and last name of each full-time faculty member along with their affiliated institution. The search results were filtered to only include NIH funding for full-time faculty members listed as principal investigators rather than as coinvestigators. The fiscal year total cost by institute/center for each full-time faculty member’s projects was summated to obtain the total NIH funding for the program.

The total number of publications by full-time faculty members in 2014 was obtained utilizing a PubMed search of articles indexed for MEDLINE using each faculty member’s first and last name. The authors’ affiliations were verified for each publication, and the number of publications was summed for all full-time faculty members at each residency program. If multiple authors from the same program coauthored an article, it was only counted once toward the total number of faculty publications from that program.

Program brochures for the 2014 meetings of the 5 societies were reviewed to quantify the number of lectures given by full-time faculty members in each program.

Each residency program was assigned a score from 0 to 1.0 for each of the 4 factors of academic achievement analyzed. The program with the highest number of faculty publications was assigned a score of 1.0 and the program with the lowest number of publications was assigned a score of 0. The programs in between were subsequently assigned scores from 0 to 1.0 based on the number of publications as a percentage of the number of publications from the program with the most publications.

A weighted ranking scheme was used to rank residency programs based on the relative importance of each factor. There were 3 factors that were deemed to be the most reflective of academic achievement among dermatology residency programs: amount of NIH funding received in 2014, number of publications by full-time faculty members in 2014, and number of faculty lectures given at society meetings in 2014; thus, these factors were given a weight of 1.0. The remaining factor— total number of full-time faculty members—was given a weight of 0.5. Values were totaled and programs were ranked based on the sum of these values. All quantitative analyses were performed using an electronic spreadsheet program.

Results

The overall ranking of the top 20 US dermatology residency programs in 2014 is presented in Table 1. The top 5 programs based on each of the 3 factors most reflective of academic achievement used in the weighted ranking algorithm are presented in Tables 2 through 4.

Comment

The ranking of US residency programs involves using data in an unbiased manner while also accounting for important subjective measures. In a 2015 survey of residency applicants (n=6285), the 5 most important factors for applicants in selecting a program were the program’s ability to prepare residents for future training or position, resident esprit de corps, faculty availability and involvement in teaching, depth and breadth of faculty, and variety of patients and clinical resources.³ However, these subjective measures are difficult to quantify in a standardized fashion. In its ranking of residency programs, the Doximity Residency Navigator utilizes surveys of current residents and recent alumni as well as nominations from board-certified Doximity members.¹

One of the main issues in utilizing survey data to rank residency programs is the inherent bias that most residents and alumni possess toward their own program. Moreover, the question arises whether most residents, faculty members, or recent alumni of residency programs have sufficient knowledge of other programs to rank them in a well-informed manner.

Wu et al⁴ used data from 2004 to perform the first algorithmic ranking of US dermatology programs, which was based on publications in 2001 to 2004, the amount of NIH funding in 2004, DF grants in 2001 to 2004, faculty lectures delivered at national conferences in 2004, and number of full-time faculty members on the editorial boards of the top 3 US dermatology journals and the top 4 subspecialty journals. Aquino et al² provided updated rankings that utilized a weighted algorithm to collect data from 2008 related to a number of factors, including annual amount of NIH and DF funding received, number of publications by full-time faculty members, number of faculty lectures given at 5 annual society meetings, and number of full-time faculty members who were on the editorial boards of 6 dermatology journals with the highest impact factors. The top 5 ranked programs based on the 2008 data were the University of California, San Francisco (San Francisco, California); Northwestern University (Chicago, Illinois); University of Pennsylvania (Philadelphia, Pennsylvania); Yale University (New Haven, Connecticut); and Stanford University (Stanford, California).²

The current ranking algorithm is more indicative of a residency program’s commitment to research and scholarship, with an assumption that successful clinical training is offered. Leading researchers in the field also are usually known to be clinical experts, but the current data does not take into account the frequency, quality, or methodology of teaching provided to residents. Perhaps the most objective measure reflecting the quality of resident education would be American Board of Dermatology examination scores, but these data are not publically available. Additional factors such as the percentage of residents who received fellowship positions; diversity of the patient population; and number and extent of surgical, cosmetic, or laser procedures performed also are not readily available. Doximity provides board pass rates for each residency program, but these data are self-reported and are not taken into account in their rankings.¹

The current study aimed to utilize publicly available data to rank US dermatology residency programs based on objective measures of academic achievement. A recent study showed that 531 of 793 applicants (67%) to emergency medicine residency programs were aware of the Doximity residency rankings.One-quarter of these applicants made changes to their rank list based on this data, demonstrating that residency rankings may impact applicant decision-making.⁵ In the future, the most accurate and unbiased rankings may be performed if each residency program joins a cooperative effort to provide more objective data about the training they provide and utilizes a standardized survey system for current residents and recent graduates to evaluate important subjective measures.

Conclusion

Based on our weighted ranking algorithm, the top 5 dermatology residency programs in 2014 were Harvard University (Boston, Massachusetts); University of California, San Francisco (San Francisco, California); Stanford University (Stanford, California); University of Pennsylvania (Philadelphia, Pennsylvania); and Emory University (Atlanta, Georgia).

Acknowledgments
We thank all of the program coordinators, full-time faculty members, program directors, and chairs who provided responses to our inquiries for additional information about their residency programs.

Rankings of US residency programs based on academic achievement are a resource for fourth-year medical students applying for residency through the National Resident Matching Program. They also highlight the leading academic training programs in each medical specialty. Currently, the Doximity Residency Navigator (https://residency.doximity.com) provides rankings of US residency programs based on either subjective or objective criteria. The subjective rankings utilize current resident and recent alumni satisfaction surveys as well as nominations from board-certified Doximity members who were asked to nominate up to 5 residency programs in their specialty that offer the best clinical training. The objective rankings are based on measurement of research output, which is calculated from the collective h-index of publications authored by graduating alumni within the last 15 years as well as the amount of research funding awarded.¹

Aquino et al² provided a ranking of US dermatology residency programs using alternative objective data measures (as of December 31, 2008) from the Doximity algorithm, including National Institutes of Health (NIH) and Dermatology Foundation (DF) funding, number of publications by full-time faculty members, number of faculty lectures given at annual meetings of 5 societies, and number of full-time faculty members serving on the editorial boards of 6 dermatology journals. The current study is an update to those rankings utilizing data from 2014.

Methods

The following data for each dermatology residency program were obtained to formulate the rankings: number of full-time faculty members, amount of NIH funding received in 2014 (https://report.nih.gov/), number of publications by full-time faculty members in 2014 (http://www.ncbi.nlm.nih.gov/pubmed/), and the number of faculty lectures given at annual meetings of 5 societies in 2014 (American Academy of Dermatology, the Society for Investigative Dermatology, the American Society of Dermatopathology, the Society for Pediatric Dermatology, and the American Society for Dermatologic Surgery). This study was approved by the institutional review board at Kaiser Permanente Southern California.

The names of all US dermatology residency programs were obtained as of December 31, 2014, from FREIDA Online using the search term dermatology. An email was sent to a representative from each residency program (eg, residency program coordinator, program director, full-time faculty member) requesting confirmation of a list of full-time faculty members in the program, excluding part-time and volunteer faculty. If a response was not obtained or the representative declined to participate, a list was compiled using available information from that residency program’s website.

National Institutes of Health funding for 2014 was obtained for individual faculty members from the NIH Research Portfolio Online Reporting Tools expenditures and reports (https://projectreporter.nih.gov/reporter.cfm) by searching the first and last name of each full-time faculty member along with their affiliated institution. The search results were filtered to only include NIH funding for full-time faculty members listed as principal investigators rather than as coinvestigators. The fiscal year total cost by institute/center for each full-time faculty member’s projects was summated to obtain the total NIH funding for the program.

The total number of publications by full-time faculty members in 2014 was obtained utilizing a PubMed search of articles indexed for MEDLINE using each faculty member’s first and last name. The authors’ affiliations were verified for each publication, and the number of publications was summed for all full-time faculty members at each residency program. If multiple authors from the same program coauthored an article, it was only counted once toward the total number of faculty publications from that program.

Program brochures for the 2014 meetings of the 5 societies were reviewed to quantify the number of lectures given by full-time faculty members in each program.

Each residency program was assigned a score from 0 to 1.0 for each of the 4 factors of academic achievement analyzed. The program with the highest number of faculty publications was assigned a score of 1.0 and the program with the lowest number of publications was assigned a score of 0. The programs in between were subsequently assigned scores from 0 to 1.0 based on the number of publications as a percentage of the number of publications from the program with the most publications.

A weighted ranking scheme was used to rank residency programs based on the relative importance of each factor. There were 3 factors that were deemed to be the most reflective of academic achievement among dermatology residency programs: amount of NIH funding received in 2014, number of publications by full-time faculty members in 2014, and number of faculty lectures given at society meetings in 2014; thus, these factors were given a weight of 1.0. The remaining factor— total number of full-time faculty members—was given a weight of 0.5. Values were totaled and programs were ranked based on the sum of these values. All quantitative analyses were performed using an electronic spreadsheet program.

Results

The overall ranking of the top 20 US dermatology residency programs in 2014 is presented in Table 1. The top 5 programs based on each of the 3 factors most reflective of academic achievement used in the weighted ranking algorithm are presented in Tables 2 through 4.

Comment

The ranking of US residency programs involves using data in an unbiased manner while also accounting for important subjective measures. In a 2015 survey of residency applicants (n=6285), the 5 most important factors for applicants in selecting a program were the program’s ability to prepare residents for future training or position, resident esprit de corps, faculty availability and involvement in teaching, depth and breadth of faculty, and variety of patients and clinical resources.³ However, these subjective measures are difficult to quantify in a standardized fashion. In its ranking of residency programs, the Doximity Residency Navigator utilizes surveys of current residents and recent alumni as well as nominations from board-certified Doximity members.¹

One of the main issues in utilizing survey data to rank residency programs is the inherent bias that most residents and alumni possess toward their own program. Moreover, the question arises whether most residents, faculty members, or recent alumni of residency programs have sufficient knowledge of other programs to rank them in a well-informed manner.

Wu et al⁴ used data from 2004 to perform the first algorithmic ranking of US dermatology programs, which was based on publications in 2001 to 2004, the amount of NIH funding in 2004, DF grants in 2001 to 2004, faculty lectures delivered at national conferences in 2004, and number of full-time faculty members on the editorial boards of the top 3 US dermatology journals and the top 4 subspecialty journals. Aquino et al² provided updated rankings that utilized a weighted algorithm to collect data from 2008 related to a number of factors, including annual amount of NIH and DF funding received, number of publications by full-time faculty members, number of faculty lectures given at 5 annual society meetings, and number of full-time faculty members who were on the editorial boards of 6 dermatology journals with the highest impact factors. The top 5 ranked programs based on the 2008 data were the University of California, San Francisco (San Francisco, California); Northwestern University (Chicago, Illinois); University of Pennsylvania (Philadelphia, Pennsylvania); Yale University (New Haven, Connecticut); and Stanford University (Stanford, California).²

The current ranking algorithm is more indicative of a residency program’s commitment to research and scholarship, with an assumption that successful clinical training is offered. Leading researchers in the field also are usually known to be clinical experts, but the current data does not take into account the frequency, quality, or methodology of teaching provided to residents. Perhaps the most objective measure reflecting the quality of resident education would be American Board of Dermatology examination scores, but these data are not publically available. Additional factors such as the percentage of residents who received fellowship positions; diversity of the patient population; and number and extent of surgical, cosmetic, or laser procedures performed also are not readily available. Doximity provides board pass rates for each residency program, but these data are self-reported and are not taken into account in their rankings.¹

The current study aimed to utilize publicly available data to rank US dermatology residency programs based on objective measures of academic achievement. A recent study showed that 531 of 793 applicants (67%) to emergency medicine residency programs were aware of the Doximity residency rankings.One-quarter of these applicants made changes to their rank list based on this data, demonstrating that residency rankings may impact applicant decision-making.⁵ In the future, the most accurate and unbiased rankings may be performed if each residency program joins a cooperative effort to provide more objective data about the training they provide and utilizes a standardized survey system for current residents and recent graduates to evaluate important subjective measures.

Conclusion

Based on our weighted ranking algorithm, the top 5 dermatology residency programs in 2014 were Harvard University (Boston, Massachusetts); University of California, San Francisco (San Francisco, California); Stanford University (Stanford, California); University of Pennsylvania (Philadelphia, Pennsylvania); and Emory University (Atlanta, Georgia).

Acknowledgments
We thank all of the program coordinators, full-time faculty members, program directors, and chairs who provided responses to our inquiries for additional information about their residency programs.

Rankings of US residency programs based on academic achievement are a resource for fourth-year medical students applying for residency through the National Resident Matching Program. They also highlight the leading academic training programs in each medical specialty. Currently, the Doximity Residency Navigator (https://residency.doximity.com) provides rankings of US residency programs based on either subjective or objective criteria. The subjective rankings utilize current resident and recent alumni satisfaction surveys as well as nominations from board-certified Doximity members who were asked to nominate up to 5 residency programs in their specialty that offer the best clinical training. The objective rankings are based on measurement of research output, which is calculated from the collective h-index of publications authored by graduating alumni within the last 15 years as well as the amount of research funding awarded.¹

Aquino et al² provided a ranking of US dermatology residency programs using alternative objective data measures (as of December 31, 2008) from the Doximity algorithm, including National Institutes of Health (NIH) and Dermatology Foundation (DF) funding, number of publications by full-time faculty members, number of faculty lectures given at annual meetings of 5 societies, and number of full-time faculty members serving on the editorial boards of 6 dermatology journals. The current study is an update to those rankings utilizing data from 2014.

Methods

The following data for each dermatology residency program were obtained to formulate the rankings: number of full-time faculty members, amount of NIH funding received in 2014 (https://report.nih.gov/), number of publications by full-time faculty members in 2014 (http://www.ncbi.nlm.nih.gov/pubmed/), and the number of faculty lectures given at annual meetings of 5 societies in 2014 (American Academy of Dermatology, the Society for Investigative Dermatology, the American Society of Dermatopathology, the Society for Pediatric Dermatology, and the American Society for Dermatologic Surgery). This study was approved by the institutional review board at Kaiser Permanente Southern California.

The names of all US dermatology residency programs were obtained as of December 31, 2014, from FREIDA Online using the search term dermatology. An email was sent to a representative from each residency program (eg, residency program coordinator, program director, full-time faculty member) requesting confirmation of a list of full-time faculty members in the program, excluding part-time and volunteer faculty. If a response was not obtained or the representative declined to participate, a list was compiled using available information from that residency program’s website.

National Institutes of Health funding for 2014 was obtained for individual faculty members from the NIH Research Portfolio Online Reporting Tools expenditures and reports (https://projectreporter.nih.gov/reporter.cfm) by searching the first and last name of each full-time faculty member along with their affiliated institution. The search results were filtered to only include NIH funding for full-time faculty members listed as principal investigators rather than as coinvestigators. The fiscal year total cost by institute/center for each full-time faculty member’s projects was summated to obtain the total NIH funding for the program.

The total number of publications by full-time faculty members in 2014 was obtained utilizing a PubMed search of articles indexed for MEDLINE using each faculty member’s first and last name. The authors’ affiliations were verified for each publication, and the number of publications was summed for all full-time faculty members at each residency program. If multiple authors from the same program coauthored an article, it was only counted once toward the total number of faculty publications from that program.

Program brochures for the 2014 meetings of the 5 societies were reviewed to quantify the number of lectures given by full-time faculty members in each program.

Each residency program was assigned a score from 0 to 1.0 for each of the 4 factors of academic achievement analyzed. The program with the highest number of faculty publications was assigned a score of 1.0 and the program with the lowest number of publications was assigned a score of 0. The programs in between were subsequently assigned scores from 0 to 1.0 based on the number of publications as a percentage of the number of publications from the program with the most publications.

A weighted ranking scheme was used to rank residency programs based on the relative importance of each factor. There were 3 factors that were deemed to be the most reflective of academic achievement among dermatology residency programs: amount of NIH funding received in 2014, number of publications by full-time faculty members in 2014, and number of faculty lectures given at society meetings in 2014; thus, these factors were given a weight of 1.0. The remaining factor— total number of full-time faculty members—was given a weight of 0.5. Values were totaled and programs were ranked based on the sum of these values. All quantitative analyses were performed using an electronic spreadsheet program.

Results

The overall ranking of the top 20 US dermatology residency programs in 2014 is presented in Table 1. The top 5 programs based on each of the 3 factors most reflective of academic achievement used in the weighted ranking algorithm are presented in Tables 2 through 4.

Comment

The ranking of US residency programs involves using data in an unbiased manner while also accounting for important subjective measures. In a 2015 survey of residency applicants (n=6285), the 5 most important factors for applicants in selecting a program were the program’s ability to prepare residents for future training or position, resident esprit de corps, faculty availability and involvement in teaching, depth and breadth of faculty, and variety of patients and clinical resources.³ However, these subjective measures are difficult to quantify in a standardized fashion. In its ranking of residency programs, the Doximity Residency Navigator utilizes surveys of current residents and recent alumni as well as nominations from board-certified Doximity members.¹

One of the main issues in utilizing survey data to rank residency programs is the inherent bias that most residents and alumni possess toward their own program. Moreover, the question arises whether most residents, faculty members, or recent alumni of residency programs have sufficient knowledge of other programs to rank them in a well-informed manner.

Wu et al⁴ used data from 2004 to perform the first algorithmic ranking of US dermatology programs, which was based on publications in 2001 to 2004, the amount of NIH funding in 2004, DF grants in 2001 to 2004, faculty lectures delivered at national conferences in 2004, and number of full-time faculty members on the editorial boards of the top 3 US dermatology journals and the top 4 subspecialty journals. Aquino et al² provided updated rankings that utilized a weighted algorithm to collect data from 2008 related to a number of factors, including annual amount of NIH and DF funding received, number of publications by full-time faculty members, number of faculty lectures given at 5 annual society meetings, and number of full-time faculty members who were on the editorial boards of 6 dermatology journals with the highest impact factors. The top 5 ranked programs based on the 2008 data were the University of California, San Francisco (San Francisco, California); Northwestern University (Chicago, Illinois); University of Pennsylvania (Philadelphia, Pennsylvania); Yale University (New Haven, Connecticut); and Stanford University (Stanford, California).²

The current ranking algorithm is more indicative of a residency program’s commitment to research and scholarship, with an assumption that successful clinical training is offered. Leading researchers in the field also are usually known to be clinical experts, but the current data does not take into account the frequency, quality, or methodology of teaching provided to residents. Perhaps the most objective measure reflecting the quality of resident education would be American Board of Dermatology examination scores, but these data are not publically available. Additional factors such as the percentage of residents who received fellowship positions; diversity of the patient population; and number and extent of surgical, cosmetic, or laser procedures performed also are not readily available. Doximity provides board pass rates for each residency program, but these data are self-reported and are not taken into account in their rankings.¹

The current study aimed to utilize publicly available data to rank US dermatology residency programs based on objective measures of academic achievement. A recent study showed that 531 of 793 applicants (67%) to emergency medicine residency programs were aware of the Doximity residency rankings.One-quarter of these applicants made changes to their rank list based on this data, demonstrating that residency rankings may impact applicant decision-making.⁵ In the future, the most accurate and unbiased rankings may be performed if each residency program joins a cooperative effort to provide more objective data about the training they provide and utilizes a standardized survey system for current residents and recent graduates to evaluate important subjective measures.

Conclusion

Based on our weighted ranking algorithm, the top 5 dermatology residency programs in 2014 were Harvard University (Boston, Massachusetts); University of California, San Francisco (San Francisco, California); Stanford University (Stanford, California); University of Pennsylvania (Philadelphia, Pennsylvania); and Emory University (Atlanta, Georgia).

Acknowledgments
We thank all of the program coordinators, full-time faculty members, program directors, and chairs who provided responses to our inquiries for additional information about their residency programs.

The VHA is the largest healthcare delivery system in the U.S. It includes 146 medical centers (VAMCs), 1,063 community-based outpatient centers (CBOCs) and various other sites of care. General Omar Bradley, the first VA Secretary, established education as one of VA’s 4 statutory missions in Policy Memorandum No.2.¹ In addition to training physicians to care for active-duty service members and veterans, 38 USC §7302 directs the VA to assist in providing an adequate supply of health personnel. The 4 statutory missions of the VA are inclusive of not only developing, operating, and maintaining a health care system for veterans, but also including contingency support services as part of emergency preparedness, conducting research, and offering a program of education for health professions.

Background

Today, with few exceptions, the VHA does not act as a graduate medical education (GME) sponsoring institution. Through its Office of Academic Affiliations (OAA), the VHA develops partnerships with Liaison Committee for Medical Education (LCME)/American Osteopathic Association (AOA)-approved medical colleges/universities and with institutions that sponsor Accreditation Council for Graduate Medical Education (ACGME)/AOA-accredited residency program-sponsoring institutions. These collaborations include 144 out of 149 allopathic medical schools and all 34 osteopathic medical schools. The VHA provided training to 43,565 medical residents and 24,683 medical students through these partnerships in 2017.² Since funding of the GME positions is not provided through the Centers for Medicare & Medicaid Services (CMS), program sponsors may use these partnerships to expand GME positions beyond their funding (but not ACGME) cap.

The gap between supply and demand of physicians continues to grow nationally.^3,4 This gap is particularly significant in rural and other underserved areas. U.S. Census Bureau data show that about 5 million veterans (24%) live in rural areas.⁵ Compared with the urban veteran population, the rural veteran experiences higher disease prevalence and lower physical and mental quality-of-life scores.⁶ Addressing the problem of physician shortages is a mission-critical priority for the VHA.⁷

With an eye toward enhancing 2 of the 4 statutory missions of the VA and to mitigate the shortage of physicians and improve the access of veterans to VHA medical services, on August 7, 2014, the Veterans Access, Choice, and Accountability Act of 2014 (Public Law [PL] 113-146), known as the Choice Act was enacted.⁸ Title III, §301(b) of the Choice Act requires VHA to increase GME residency positions by:

Establishing new medical residency programs, or ensuring that already established medical residency programs have a sufficient number of residency positions, at any VHA medical facility that is: (a) experiencing a shortage of physicians and (b) located in a community that is designated as a health professional shortage area.

The legislation specifies that priority must be placed on medical occupations that experience the largest staffing shortages throughout the VHA and “programs in primary care, mental health, and any other specialty that the Secretary of the VA determines appropriate.” The Choice Act authorized the VHA to increase the number of GME residency positions by up to 1,500 over a 5-year period. In December 2016, as amended by PL 114–315, Title VI, §617(a), this authorization was extended by another 5 years for a total of 10 years and will run through 2024.⁹

GME Development/Distribution

To distribute these newly created GME positions as mandated by Congress, the OAA is using a system with 3 types of request for proposal (RFP) applications. These include planning, infrastructure, and position grants. This phased approach was taken with the understanding that the development of new training sites requires a properly staffed education office and dedicated faculty time. Planning and infrastructure grants provide start-up funds for smaller VAMCs, allowing them to keep facility resources focused on their clinical mission.

Planning grants (of up to $250,000 over 2 years) primarily were designed for VA facilities with no or low numbers of physician residents at the desired teaching location. Priority was given to facilities in rural and/or underserved areas as well as those developing new affiliations. Applications were reviewed by OAA staff along with peer-selected Designated Education Officers (DEOs) from VA facilities across the nation that were not applying for the grants. Awards were based on the priorities mentioned earlier, with additional credit for programs focused on 2 VHA fundamental services areas—primary care and/or mental health training. Facilities receiving planning grants were mentored by an OAA physician staff member, anticipating a 2- to 3-year time line to request positions and begin GME training.

Infrastructure grants (of up to $520,000 used over 2-3 years) were designed as bridge funds after approval of Veterans Access, Choice, and Accountability Act (VACAA) GME positions. Infrastructure grants are appropriate to sustain a local education office, develop VA faculty, purchase equipment, and make minor modifications to the clinical space in the VAMCs or CBOCs to enhance the learning environment during the period before VA supportive funds from the Veterans Equitable Resource Allocation (VERA) (similar to indirect GME funds from CMS) become available. Applications were managed the same as planning grant submissions.

Position RFPs, unlike planning and infrastructure RFPs, are available to all VAMCs. The primary purpose of the VACAA Position RFP is to fund new positions in primary care and psychiatry. Graduate medical education positions in subspecialty programs also are considered when there is documentation of critical need to improve access to these services. Applications were reviewed by OAA staff along with selected DEOs from VA facilities around the U.S. Award criteria prioritized primary care (family medicine, internal medicine, geriatrics), and mental health (psychiatry and psychiatry subspecialties). Priority also was given to positions in areas with a documented shortage of physicians and areas with high concentrations of veterans.

Current Progress

To date the OAA has offered 3 RFP cycles consisting of planning/infrastructure grants, and 4 RFP cycles for salary/benefit support for additional resident full-time equivalent (FTE) positions. Resident positions were defined as residency or fellowship FTEs that were part of an ACGME or AOA-accredited training program. Figure 1 illustrates the geographic distribution of awarded GME positions. 

In primary care specialties (family medicine, internal medicine, and geriatrics, a total of 349.4 FTE positions have been approved (Table 1). Due to a low number of applications, only 6.3 of these positions were awarded in geriatrics. In mental health, 167.6 FTE positions have been approved, whereas in critical needs specialties (needed to support rural/underserved healthcare and improve specialty access) 256.5 FTE positions have been added. 

Discussion

There are several important desired short-term outcomes from VACAA. The first is improved access to high-quality care for both rural and urban veterans. There is an emphasis on primary care and mental health because shortages in these areas across the U.S. are well established.^3,4,10 Likewise, rural areas have been prioritized because often there is a disparity of care. 

One area of concern is the small number of applicants in geriatrics. Even with VACAA specifically targeting geriatrics as a primary care specialty, we have only received enough applications to approve 6.3 positions over the first 3 years of the program. As the veteran and overall population in the U.S. ages, it is important to develop a medical workforce that is willing and able to address their needs.

The VACAA statute is not intended to alter medical students’ career choice but rather to provide funded positions for those choosing primary care, geriatrics, psychiatry (including psychiatric subspecialties), and experience in the VA clinical settings. The hope is that this experience will encourage practitioners to competently care for veterans after training in the VA and/or other civilian settings.

By enabling smaller VA facilities to become training sites through planning and infrastructure grants, residents have the opportunity to gain experience in more rural settings. Physicians who choose to train in rural areas are likely to spend time practicing in those areas after they complete training.¹⁵ The process of developing facilities with no GME into training sitestakes time and resources. Establishing an education office and choosing site directors and core faculty are all important steps that must be done before resident rotations begin. Resources provided through VACAA have enabled the VHA to reduce the number of VAMCs with no GME activity to just 3.

Another benefit of VACAA GME expansion is the opportunity to engage new LCME/AOA-accredited medical schools and ACGME/AOA-accredited residency-sponsoring institutions.^16,17 Representatives of these institutions may have perceived a reluctance of their local VAs to develop GME affiliations in the past. This statute has enabled many VAMCs to use nontraditional training sites and modalities to overcome barriers and create new academic affiliations.

However, VACAA only provides funds for training that occurs in established VA sites of care. This can hinder the development of partnerships where other funding sources are required for non-VA rotations. Another VACAA limitation is that it does not fund undergraduate medical education as does the Armed Forces Health Professional Scholarship Program (HPSP). In addition, the primary financial relationship is between the VA and the sponsoring institution, thus VHA cannot send residents to underserved locations.

Conclusion

The VHA has a rich tradition of educating physician and other health care providers in the U.S. More than 60% of U.S. trained physicians received a portion of their training through VHA.² Through VACAA GME expansion initiative, the 113th Congress has asked VHA to continue its important training mission “to bind up the Nations wounds” and “to care for him who shall have borne the battle.”¹⁸

Acknowledgments
In memoriam – Robert Louis Jesse MD, PhD. Dr. Jesse, the Chief of the Office of Academic Affiliations passed away on September 2, 2017, at age 64. He had an illustrious medical career as a cardiologist and served in many leadership roles including Principal Deputy Under Secretary for Health in the U.S. Department of Veterans Affairs. His expertise, visionary leadership, and friendship will be missed by all involved in the VA’s academic training mission but particularly by those of us who worked for and with him at OAA.

The VHA is the largest healthcare delivery system in the U.S. It includes 146 medical centers (VAMCs), 1,063 community-based outpatient centers (CBOCs) and various other sites of care. General Omar Bradley, the first VA Secretary, established education as one of VA’s 4 statutory missions in Policy Memorandum No.2.¹ In addition to training physicians to care for active-duty service members and veterans, 38 USC §7302 directs the VA to assist in providing an adequate supply of health personnel. The 4 statutory missions of the VA are inclusive of not only developing, operating, and maintaining a health care system for veterans, but also including contingency support services as part of emergency preparedness, conducting research, and offering a program of education for health professions.

Background

Today, with few exceptions, the VHA does not act as a graduate medical education (GME) sponsoring institution. Through its Office of Academic Affiliations (OAA), the VHA develops partnerships with Liaison Committee for Medical Education (LCME)/American Osteopathic Association (AOA)-approved medical colleges/universities and with institutions that sponsor Accreditation Council for Graduate Medical Education (ACGME)/AOA-accredited residency program-sponsoring institutions. These collaborations include 144 out of 149 allopathic medical schools and all 34 osteopathic medical schools. The VHA provided training to 43,565 medical residents and 24,683 medical students through these partnerships in 2017.² Since funding of the GME positions is not provided through the Centers for Medicare & Medicaid Services (CMS), program sponsors may use these partnerships to expand GME positions beyond their funding (but not ACGME) cap.

The gap between supply and demand of physicians continues to grow nationally.^3,4 This gap is particularly significant in rural and other underserved areas. U.S. Census Bureau data show that about 5 million veterans (24%) live in rural areas.⁵ Compared with the urban veteran population, the rural veteran experiences higher disease prevalence and lower physical and mental quality-of-life scores.⁶ Addressing the problem of physician shortages is a mission-critical priority for the VHA.⁷

With an eye toward enhancing 2 of the 4 statutory missions of the VA and to mitigate the shortage of physicians and improve the access of veterans to VHA medical services, on August 7, 2014, the Veterans Access, Choice, and Accountability Act of 2014 (Public Law [PL] 113-146), known as the Choice Act was enacted.⁸ Title III, §301(b) of the Choice Act requires VHA to increase GME residency positions by:

Establishing new medical residency programs, or ensuring that already established medical residency programs have a sufficient number of residency positions, at any VHA medical facility that is: (a) experiencing a shortage of physicians and (b) located in a community that is designated as a health professional shortage area.

The legislation specifies that priority must be placed on medical occupations that experience the largest staffing shortages throughout the VHA and “programs in primary care, mental health, and any other specialty that the Secretary of the VA determines appropriate.” The Choice Act authorized the VHA to increase the number of GME residency positions by up to 1,500 over a 5-year period. In December 2016, as amended by PL 114–315, Title VI, §617(a), this authorization was extended by another 5 years for a total of 10 years and will run through 2024.⁹

GME Development/Distribution

To distribute these newly created GME positions as mandated by Congress, the OAA is using a system with 3 types of request for proposal (RFP) applications. These include planning, infrastructure, and position grants. This phased approach was taken with the understanding that the development of new training sites requires a properly staffed education office and dedicated faculty time. Planning and infrastructure grants provide start-up funds for smaller VAMCs, allowing them to keep facility resources focused on their clinical mission.

Planning grants (of up to $250,000 over 2 years) primarily were designed for VA facilities with no or low numbers of physician residents at the desired teaching location. Priority was given to facilities in rural and/or underserved areas as well as those developing new affiliations. Applications were reviewed by OAA staff along with peer-selected Designated Education Officers (DEOs) from VA facilities across the nation that were not applying for the grants. Awards were based on the priorities mentioned earlier, with additional credit for programs focused on 2 VHA fundamental services areas—primary care and/or mental health training. Facilities receiving planning grants were mentored by an OAA physician staff member, anticipating a 2- to 3-year time line to request positions and begin GME training.

Infrastructure grants (of up to $520,000 used over 2-3 years) were designed as bridge funds after approval of Veterans Access, Choice, and Accountability Act (VACAA) GME positions. Infrastructure grants are appropriate to sustain a local education office, develop VA faculty, purchase equipment, and make minor modifications to the clinical space in the VAMCs or CBOCs to enhance the learning environment during the period before VA supportive funds from the Veterans Equitable Resource Allocation (VERA) (similar to indirect GME funds from CMS) become available. Applications were managed the same as planning grant submissions.

Position RFPs, unlike planning and infrastructure RFPs, are available to all VAMCs. The primary purpose of the VACAA Position RFP is to fund new positions in primary care and psychiatry. Graduate medical education positions in subspecialty programs also are considered when there is documentation of critical need to improve access to these services. Applications were reviewed by OAA staff along with selected DEOs from VA facilities around the U.S. Award criteria prioritized primary care (family medicine, internal medicine, geriatrics), and mental health (psychiatry and psychiatry subspecialties). Priority also was given to positions in areas with a documented shortage of physicians and areas with high concentrations of veterans.

Current Progress

To date the OAA has offered 3 RFP cycles consisting of planning/infrastructure grants, and 4 RFP cycles for salary/benefit support for additional resident full-time equivalent (FTE) positions. Resident positions were defined as residency or fellowship FTEs that were part of an ACGME or AOA-accredited training program. Figure 1 illustrates the geographic distribution of awarded GME positions. 

In primary care specialties (family medicine, internal medicine, and geriatrics, a total of 349.4 FTE positions have been approved (Table 1). Due to a low number of applications, only 6.3 of these positions were awarded in geriatrics. In mental health, 167.6 FTE positions have been approved, whereas in critical needs specialties (needed to support rural/underserved healthcare and improve specialty access) 256.5 FTE positions have been added. 

Discussion

There are several important desired short-term outcomes from VACAA. The first is improved access to high-quality care for both rural and urban veterans. There is an emphasis on primary care and mental health because shortages in these areas across the U.S. are well established.^3,4,10 Likewise, rural areas have been prioritized because often there is a disparity of care. 

One area of concern is the small number of applicants in geriatrics. Even with VACAA specifically targeting geriatrics as a primary care specialty, we have only received enough applications to approve 6.3 positions over the first 3 years of the program. As the veteran and overall population in the U.S. ages, it is important to develop a medical workforce that is willing and able to address their needs.

The VACAA statute is not intended to alter medical students’ career choice but rather to provide funded positions for those choosing primary care, geriatrics, psychiatry (including psychiatric subspecialties), and experience in the VA clinical settings. The hope is that this experience will encourage practitioners to competently care for veterans after training in the VA and/or other civilian settings.

By enabling smaller VA facilities to become training sites through planning and infrastructure grants, residents have the opportunity to gain experience in more rural settings. Physicians who choose to train in rural areas are likely to spend time practicing in those areas after they complete training.¹⁵ The process of developing facilities with no GME into training sitestakes time and resources. Establishing an education office and choosing site directors and core faculty are all important steps that must be done before resident rotations begin. Resources provided through VACAA have enabled the VHA to reduce the number of VAMCs with no GME activity to just 3.

Another benefit of VACAA GME expansion is the opportunity to engage new LCME/AOA-accredited medical schools and ACGME/AOA-accredited residency-sponsoring institutions.^16,17 Representatives of these institutions may have perceived a reluctance of their local VAs to develop GME affiliations in the past. This statute has enabled many VAMCs to use nontraditional training sites and modalities to overcome barriers and create new academic affiliations.

However, VACAA only provides funds for training that occurs in established VA sites of care. This can hinder the development of partnerships where other funding sources are required for non-VA rotations. Another VACAA limitation is that it does not fund undergraduate medical education as does the Armed Forces Health Professional Scholarship Program (HPSP). In addition, the primary financial relationship is between the VA and the sponsoring institution, thus VHA cannot send residents to underserved locations.

Conclusion

The VHA has a rich tradition of educating physician and other health care providers in the U.S. More than 60% of U.S. trained physicians received a portion of their training through VHA.² Through VACAA GME expansion initiative, the 113th Congress has asked VHA to continue its important training mission “to bind up the Nations wounds” and “to care for him who shall have borne the battle.”¹⁸

Acknowledgments
In memoriam – Robert Louis Jesse MD, PhD. Dr. Jesse, the Chief of the Office of Academic Affiliations passed away on September 2, 2017, at age 64. He had an illustrious medical career as a cardiologist and served in many leadership roles including Principal Deputy Under Secretary for Health in the U.S. Department of Veterans Affairs. His expertise, visionary leadership, and friendship will be missed by all involved in the VA’s academic training mission but particularly by those of us who worked for and with him at OAA.

The VHA is the largest healthcare delivery system in the U.S. It includes 146 medical centers (VAMCs), 1,063 community-based outpatient centers (CBOCs) and various other sites of care. General Omar Bradley, the first VA Secretary, established education as one of VA’s 4 statutory missions in Policy Memorandum No.2.¹ In addition to training physicians to care for active-duty service members and veterans, 38 USC §7302 directs the VA to assist in providing an adequate supply of health personnel. The 4 statutory missions of the VA are inclusive of not only developing, operating, and maintaining a health care system for veterans, but also including contingency support services as part of emergency preparedness, conducting research, and offering a program of education for health professions.

Background

Today, with few exceptions, the VHA does not act as a graduate medical education (GME) sponsoring institution. Through its Office of Academic Affiliations (OAA), the VHA develops partnerships with Liaison Committee for Medical Education (LCME)/American Osteopathic Association (AOA)-approved medical colleges/universities and with institutions that sponsor Accreditation Council for Graduate Medical Education (ACGME)/AOA-accredited residency program-sponsoring institutions. These collaborations include 144 out of 149 allopathic medical schools and all 34 osteopathic medical schools. The VHA provided training to 43,565 medical residents and 24,683 medical students through these partnerships in 2017.² Since funding of the GME positions is not provided through the Centers for Medicare & Medicaid Services (CMS), program sponsors may use these partnerships to expand GME positions beyond their funding (but not ACGME) cap.

The gap between supply and demand of physicians continues to grow nationally.^3,4 This gap is particularly significant in rural and other underserved areas. U.S. Census Bureau data show that about 5 million veterans (24%) live in rural areas.⁵ Compared with the urban veteran population, the rural veteran experiences higher disease prevalence and lower physical and mental quality-of-life scores.⁶ Addressing the problem of physician shortages is a mission-critical priority for the VHA.⁷

With an eye toward enhancing 2 of the 4 statutory missions of the VA and to mitigate the shortage of physicians and improve the access of veterans to VHA medical services, on August 7, 2014, the Veterans Access, Choice, and Accountability Act of 2014 (Public Law [PL] 113-146), known as the Choice Act was enacted.⁸ Title III, §301(b) of the Choice Act requires VHA to increase GME residency positions by:

Establishing new medical residency programs, or ensuring that already established medical residency programs have a sufficient number of residency positions, at any VHA medical facility that is: (a) experiencing a shortage of physicians and (b) located in a community that is designated as a health professional shortage area.

The legislation specifies that priority must be placed on medical occupations that experience the largest staffing shortages throughout the VHA and “programs in primary care, mental health, and any other specialty that the Secretary of the VA determines appropriate.” The Choice Act authorized the VHA to increase the number of GME residency positions by up to 1,500 over a 5-year period. In December 2016, as amended by PL 114–315, Title VI, §617(a), this authorization was extended by another 5 years for a total of 10 years and will run through 2024.⁹

GME Development/Distribution

To distribute these newly created GME positions as mandated by Congress, the OAA is using a system with 3 types of request for proposal (RFP) applications. These include planning, infrastructure, and position grants. This phased approach was taken with the understanding that the development of new training sites requires a properly staffed education office and dedicated faculty time. Planning and infrastructure grants provide start-up funds for smaller VAMCs, allowing them to keep facility resources focused on their clinical mission.

Planning grants (of up to $250,000 over 2 years) primarily were designed for VA facilities with no or low numbers of physician residents at the desired teaching location. Priority was given to facilities in rural and/or underserved areas as well as those developing new affiliations. Applications were reviewed by OAA staff along with peer-selected Designated Education Officers (DEOs) from VA facilities across the nation that were not applying for the grants. Awards were based on the priorities mentioned earlier, with additional credit for programs focused on 2 VHA fundamental services areas—primary care and/or mental health training. Facilities receiving planning grants were mentored by an OAA physician staff member, anticipating a 2- to 3-year time line to request positions and begin GME training.

Infrastructure grants (of up to $520,000 used over 2-3 years) were designed as bridge funds after approval of Veterans Access, Choice, and Accountability Act (VACAA) GME positions. Infrastructure grants are appropriate to sustain a local education office, develop VA faculty, purchase equipment, and make minor modifications to the clinical space in the VAMCs or CBOCs to enhance the learning environment during the period before VA supportive funds from the Veterans Equitable Resource Allocation (VERA) (similar to indirect GME funds from CMS) become available. Applications were managed the same as planning grant submissions.

Position RFPs, unlike planning and infrastructure RFPs, are available to all VAMCs. The primary purpose of the VACAA Position RFP is to fund new positions in primary care and psychiatry. Graduate medical education positions in subspecialty programs also are considered when there is documentation of critical need to improve access to these services. Applications were reviewed by OAA staff along with selected DEOs from VA facilities around the U.S. Award criteria prioritized primary care (family medicine, internal medicine, geriatrics), and mental health (psychiatry and psychiatry subspecialties). Priority also was given to positions in areas with a documented shortage of physicians and areas with high concentrations of veterans.

Current Progress

To date the OAA has offered 3 RFP cycles consisting of planning/infrastructure grants, and 4 RFP cycles for salary/benefit support for additional resident full-time equivalent (FTE) positions. Resident positions were defined as residency or fellowship FTEs that were part of an ACGME or AOA-accredited training program. Figure 1 illustrates the geographic distribution of awarded GME positions. 

In primary care specialties (family medicine, internal medicine, and geriatrics, a total of 349.4 FTE positions have been approved (Table 1). Due to a low number of applications, only 6.3 of these positions were awarded in geriatrics. In mental health, 167.6 FTE positions have been approved, whereas in critical needs specialties (needed to support rural/underserved healthcare and improve specialty access) 256.5 FTE positions have been added. 

Discussion

There are several important desired short-term outcomes from VACAA. The first is improved access to high-quality care for both rural and urban veterans. There is an emphasis on primary care and mental health because shortages in these areas across the U.S. are well established.^3,4,10 Likewise, rural areas have been prioritized because often there is a disparity of care. 

One area of concern is the small number of applicants in geriatrics. Even with VACAA specifically targeting geriatrics as a primary care specialty, we have only received enough applications to approve 6.3 positions over the first 3 years of the program. As the veteran and overall population in the U.S. ages, it is important to develop a medical workforce that is willing and able to address their needs.

The VACAA statute is not intended to alter medical students’ career choice but rather to provide funded positions for those choosing primary care, geriatrics, psychiatry (including psychiatric subspecialties), and experience in the VA clinical settings. The hope is that this experience will encourage practitioners to competently care for veterans after training in the VA and/or other civilian settings.

By enabling smaller VA facilities to become training sites through planning and infrastructure grants, residents have the opportunity to gain experience in more rural settings. Physicians who choose to train in rural areas are likely to spend time practicing in those areas after they complete training.¹⁵ The process of developing facilities with no GME into training sitestakes time and resources. Establishing an education office and choosing site directors and core faculty are all important steps that must be done before resident rotations begin. Resources provided through VACAA have enabled the VHA to reduce the number of VAMCs with no GME activity to just 3.

Another benefit of VACAA GME expansion is the opportunity to engage new LCME/AOA-accredited medical schools and ACGME/AOA-accredited residency-sponsoring institutions.^16,17 Representatives of these institutions may have perceived a reluctance of their local VAs to develop GME affiliations in the past. This statute has enabled many VAMCs to use nontraditional training sites and modalities to overcome barriers and create new academic affiliations.

However, VACAA only provides funds for training that occurs in established VA sites of care. This can hinder the development of partnerships where other funding sources are required for non-VA rotations. Another VACAA limitation is that it does not fund undergraduate medical education as does the Armed Forces Health Professional Scholarship Program (HPSP). In addition, the primary financial relationship is between the VA and the sponsoring institution, thus VHA cannot send residents to underserved locations.

Conclusion

The VHA has a rich tradition of educating physician and other health care providers in the U.S. More than 60% of U.S. trained physicians received a portion of their training through VHA.² Through VACAA GME expansion initiative, the 113th Congress has asked VHA to continue its important training mission “to bind up the Nations wounds” and “to care for him who shall have borne the battle.”¹⁸

Acknowledgments
In memoriam – Robert Louis Jesse MD, PhD. Dr. Jesse, the Chief of the Office of Academic Affiliations passed away on September 2, 2017, at age 64. He had an illustrious medical career as a cardiologist and served in many leadership roles including Principal Deputy Under Secretary for Health in the U.S. Department of Veterans Affairs. His expertise, visionary leadership, and friendship will be missed by all involved in the VA’s academic training mission but particularly by those of us who worked for and with him at OAA.

Dermatology residency training can feel endless at the outset; an arduous intern year followed by 3 years of specialized training. However, I have realized that, within residency, time moves quickly. As I look ahead to postresidency life, I realize that residents are all facing the same question: What do you want to be when you grow up?

You may think you have answered that question already; however, there are many different careers within the field of dermatology and no amount of studying or reading will help you choose the right one. In an attempt to make sense of these choices, I have spoken to many recent dermatology graduates over the last several months to get a sense of how they made their postresidency decisions, and I want to share their pearls.

Pearl: Explore Fellowship Opportunities Early

The first decision is whether or not to pursue a fellowship after residency. There currently are 2 Accreditation Council for Graduate Medical Education–approved fellowships after dermatology residency: dermatopathology and micrographic surgery. Pediatric dermatology is another board-certified fellowship. A list of these training programs and the requirements can be found on the American Board of Dermatology website (www.abderm.org). There also are several nonaccredited fellowships including pediatrics, cosmetics, complex medical dermatology, cutaneous oncology, and rheumatology.

Even if you are not completely committed to pursuing a fellowship, it is beneficial to explore any fellowship options early in residency. Spend extra time in any field you are considering for fellowship and consider research in the field. If there is a fellowship position at your institution, try to rotate there early in residency. Rotations at other institutions can demonstrate your interest and enthusiasm while also helping you to network within your chosen subspecialty. Several of the dermatology interest groups even sponsor rotations at outside institutions, if extra funding is needed. If recent graduates from your program have matched in fellowship, it is always a good idea to reach out to them to get program-specific advice. It takes a lot of time, confidence, and persistence to organize the opportunities that will help you maximize your fellowship potential, but it is well worth the effort.

Fellowships can occur through an official “match,” similar to residency, or can be accepted on a rolling basis. For example, many dermatopathology fellowships can begin accepting applications as early as the summer between the first and second year of residency (www.abderm.org). It is important to get this information early so that you do not miss any application deadlines.

Pearl: Prioritize Where You Want to Practice

If you have decided that fellowship is not for you, then it is time to apply for your first job as a physician. There are several big factors that help narrow the search. It is best to start the search early to allow yourself time and different options. According to the 2016 American Academy of Dermatology database, there currently are approximately 3.4 dermatologists per 100,000 Americans; however, they are unevenly distributed throughout the country. In this study, the researchers found the highest density of dermatologists on the Upper East Side of Manhattan (41.8 per 100,000 dermatologists) compared to Swainsboro, Georgia (0.45 per 100,000 dermatologists).¹

With more competition for jobs in areas with a higher concentration of dermatologists, compensation often is lower. There also are many personal factors that contribute to where you want to live and work, and if you prioritize them, it will lead to greater overall satisfaction in postresidency life.

Another large factor to consider is private practice versus academic dermatology. Academic dermatology can provide opportunities for research as well as the opportunity to work with students and residents. As part of a larger hospital system, there often is the opportunity for benefits, such as 401(k) matching, that might be less accessible in small practices.

Pearl: Get Recruiter Recommendations From Your Peers

There are many recruiting services that can help put you in touch with practices that are hiring. These services can be helpful but also can be overwhelming at times, with many emails and telephone calls. In my experience, recent graduates had mixed feelings about recruiting services. Those who had been the happiest with their recruiting experience had often gotten the name of a specific recruiter from someone else in their program who had a positive experience. Mentors at your training institution or beyond also can be a good source of information for job opportunities. It can be helpful to get involved early in the various dermatologic societies and network at academic conferences throughout your training.

Pearl: Talk to Partners and Nonpartners About the Practice’s Philosophy

When picking a private practice for your first job, make sure you get a sense of the philosophy of the practice, including the partners’ goals for the office, the patient population, and the dynamic of the office staff. If there is a cosmetic component, it is important to know what devices are available and which products are sold. It is important to talk to nonpartners at a practice and get a sense of their satisfaction. If you sign the employment contract, you will be in their shoes soon!

Pearl: Have an Attorney Review Your Contract

There are many important topics in your employment contract. After years of medical school loans and resident salary, it is easy to focus only on compensation. However, pay attention to the other aspects of reimbursement including bonuses, benefits, noncompete clauses, and call schedules. Also consider the termination policies. The general advice I have received is to have a lawyer look at your contract. Although it may be tempting to skip the lawyer’s fee and review it yourself, you may actually end up negotiating a contract that benefits you more in the long-run or avoid signing a contract that will limit you.

Dermatology residency training can feel endless at the outset; an arduous intern year followed by 3 years of specialized training. However, I have realized that, within residency, time moves quickly. As I look ahead to postresidency life, I realize that residents are all facing the same question: What do you want to be when you grow up?

You may think you have answered that question already; however, there are many different careers within the field of dermatology and no amount of studying or reading will help you choose the right one. In an attempt to make sense of these choices, I have spoken to many recent dermatology graduates over the last several months to get a sense of how they made their postresidency decisions, and I want to share their pearls.

Pearl: Explore Fellowship Opportunities Early

The first decision is whether or not to pursue a fellowship after residency. There currently are 2 Accreditation Council for Graduate Medical Education–approved fellowships after dermatology residency: dermatopathology and micrographic surgery. Pediatric dermatology is another board-certified fellowship. A list of these training programs and the requirements can be found on the American Board of Dermatology website (www.abderm.org). There also are several nonaccredited fellowships including pediatrics, cosmetics, complex medical dermatology, cutaneous oncology, and rheumatology.

Even if you are not completely committed to pursuing a fellowship, it is beneficial to explore any fellowship options early in residency. Spend extra time in any field you are considering for fellowship and consider research in the field. If there is a fellowship position at your institution, try to rotate there early in residency. Rotations at other institutions can demonstrate your interest and enthusiasm while also helping you to network within your chosen subspecialty. Several of the dermatology interest groups even sponsor rotations at outside institutions, if extra funding is needed. If recent graduates from your program have matched in fellowship, it is always a good idea to reach out to them to get program-specific advice. It takes a lot of time, confidence, and persistence to organize the opportunities that will help you maximize your fellowship potential, but it is well worth the effort.

Fellowships can occur through an official “match,” similar to residency, or can be accepted on a rolling basis. For example, many dermatopathology fellowships can begin accepting applications as early as the summer between the first and second year of residency (www.abderm.org). It is important to get this information early so that you do not miss any application deadlines.

Pearl: Prioritize Where You Want to Practice

If you have decided that fellowship is not for you, then it is time to apply for your first job as a physician. There are several big factors that help narrow the search. It is best to start the search early to allow yourself time and different options. According to the 2016 American Academy of Dermatology database, there currently are approximately 3.4 dermatologists per 100,000 Americans; however, they are unevenly distributed throughout the country. In this study, the researchers found the highest density of dermatologists on the Upper East Side of Manhattan (41.8 per 100,000 dermatologists) compared to Swainsboro, Georgia (0.45 per 100,000 dermatologists).¹

With more competition for jobs in areas with a higher concentration of dermatologists, compensation often is lower. There also are many personal factors that contribute to where you want to live and work, and if you prioritize them, it will lead to greater overall satisfaction in postresidency life.

Another large factor to consider is private practice versus academic dermatology. Academic dermatology can provide opportunities for research as well as the opportunity to work with students and residents. As part of a larger hospital system, there often is the opportunity for benefits, such as 401(k) matching, that might be less accessible in small practices.

Pearl: Get Recruiter Recommendations From Your Peers

There are many recruiting services that can help put you in touch with practices that are hiring. These services can be helpful but also can be overwhelming at times, with many emails and telephone calls. In my experience, recent graduates had mixed feelings about recruiting services. Those who had been the happiest with their recruiting experience had often gotten the name of a specific recruiter from someone else in their program who had a positive experience. Mentors at your training institution or beyond also can be a good source of information for job opportunities. It can be helpful to get involved early in the various dermatologic societies and network at academic conferences throughout your training.

Pearl: Talk to Partners and Nonpartners About the Practice’s Philosophy

When picking a private practice for your first job, make sure you get a sense of the philosophy of the practice, including the partners’ goals for the office, the patient population, and the dynamic of the office staff. If there is a cosmetic component, it is important to know what devices are available and which products are sold. It is important to talk to nonpartners at a practice and get a sense of their satisfaction. If you sign the employment contract, you will be in their shoes soon!

Pearl: Have an Attorney Review Your Contract

There are many important topics in your employment contract. After years of medical school loans and resident salary, it is easy to focus only on compensation. However, pay attention to the other aspects of reimbursement including bonuses, benefits, noncompete clauses, and call schedules. Also consider the termination policies. The general advice I have received is to have a lawyer look at your contract. Although it may be tempting to skip the lawyer’s fee and review it yourself, you may actually end up negotiating a contract that benefits you more in the long-run or avoid signing a contract that will limit you.

Dermatology residency training can feel endless at the outset; an arduous intern year followed by 3 years of specialized training. However, I have realized that, within residency, time moves quickly. As I look ahead to postresidency life, I realize that residents are all facing the same question: What do you want to be when you grow up?

You may think you have answered that question already; however, there are many different careers within the field of dermatology and no amount of studying or reading will help you choose the right one. In an attempt to make sense of these choices, I have spoken to many recent dermatology graduates over the last several months to get a sense of how they made their postresidency decisions, and I want to share their pearls.

Pearl: Explore Fellowship Opportunities Early

The first decision is whether or not to pursue a fellowship after residency. There currently are 2 Accreditation Council for Graduate Medical Education–approved fellowships after dermatology residency: dermatopathology and micrographic surgery. Pediatric dermatology is another board-certified fellowship. A list of these training programs and the requirements can be found on the American Board of Dermatology website (www.abderm.org). There also are several nonaccredited fellowships including pediatrics, cosmetics, complex medical dermatology, cutaneous oncology, and rheumatology.

Even if you are not completely committed to pursuing a fellowship, it is beneficial to explore any fellowship options early in residency. Spend extra time in any field you are considering for fellowship and consider research in the field. If there is a fellowship position at your institution, try to rotate there early in residency. Rotations at other institutions can demonstrate your interest and enthusiasm while also helping you to network within your chosen subspecialty. Several of the dermatology interest groups even sponsor rotations at outside institutions, if extra funding is needed. If recent graduates from your program have matched in fellowship, it is always a good idea to reach out to them to get program-specific advice. It takes a lot of time, confidence, and persistence to organize the opportunities that will help you maximize your fellowship potential, but it is well worth the effort.

Fellowships can occur through an official “match,” similar to residency, or can be accepted on a rolling basis. For example, many dermatopathology fellowships can begin accepting applications as early as the summer between the first and second year of residency (www.abderm.org). It is important to get this information early so that you do not miss any application deadlines.

Pearl: Prioritize Where You Want to Practice

If you have decided that fellowship is not for you, then it is time to apply for your first job as a physician. There are several big factors that help narrow the search. It is best to start the search early to allow yourself time and different options. According to the 2016 American Academy of Dermatology database, there currently are approximately 3.4 dermatologists per 100,000 Americans; however, they are unevenly distributed throughout the country. In this study, the researchers found the highest density of dermatologists on the Upper East Side of Manhattan (41.8 per 100,000 dermatologists) compared to Swainsboro, Georgia (0.45 per 100,000 dermatologists).¹

With more competition for jobs in areas with a higher concentration of dermatologists, compensation often is lower. There also are many personal factors that contribute to where you want to live and work, and if you prioritize them, it will lead to greater overall satisfaction in postresidency life.

Another large factor to consider is private practice versus academic dermatology. Academic dermatology can provide opportunities for research as well as the opportunity to work with students and residents. As part of a larger hospital system, there often is the opportunity for benefits, such as 401(k) matching, that might be less accessible in small practices.

Pearl: Get Recruiter Recommendations From Your Peers

There are many recruiting services that can help put you in touch with practices that are hiring. These services can be helpful but also can be overwhelming at times, with many emails and telephone calls. In my experience, recent graduates had mixed feelings about recruiting services. Those who had been the happiest with their recruiting experience had often gotten the name of a specific recruiter from someone else in their program who had a positive experience. Mentors at your training institution or beyond also can be a good source of information for job opportunities. It can be helpful to get involved early in the various dermatologic societies and network at academic conferences throughout your training.

Pearl: Talk to Partners and Nonpartners About the Practice’s Philosophy

When picking a private practice for your first job, make sure you get a sense of the philosophy of the practice, including the partners’ goals for the office, the patient population, and the dynamic of the office staff. If there is a cosmetic component, it is important to know what devices are available and which products are sold. It is important to talk to nonpartners at a practice and get a sense of their satisfaction. If you sign the employment contract, you will be in their shoes soon!

Pearl: Have an Attorney Review Your Contract

There are many important topics in your employment contract. After years of medical school loans and resident salary, it is easy to focus only on compensation. However, pay attention to the other aspects of reimbursement including bonuses, benefits, noncompete clauses, and call schedules. Also consider the termination policies. The general advice I have received is to have a lawyer look at your contract. Although it may be tempting to skip the lawyer’s fee and review it yourself, you may actually end up negotiating a contract that benefits you more in the long-run or avoid signing a contract that will limit you.