For Residents

This July, medical students, residents, and fellows in almost every medical and surgical specialty will join nurses at all levels of training, undergraduate and graduate pharmacists, dentists, and allied health students to train at a VA hospital. The VA Office of Academic Affiliations (OAA), which coordinates this massive educational effort, reported that in 2015, the last year for which data are available, 123,552 health care trainees were enrolled in VA programs.¹ That’s in addition to the hundreds of health care professionals trained in the 4 branches of the armed services, including students at the Uniformed Services University of the Health Sciences and those receiving a health care education through the PHS. Federal institutions are easily the largest contributors to health care education in the nation and very likely in the world.

This mission to educate the U.S. health care workforce is not new. This year marks the 70th anniversary of the collaboration between the VA and academic affiliates across the country to ensure a highly qualified cadre of health care professionals care, not only for veterans, but also for the public. Hence, the OAA motto: To educate for VA and for the nation.

When allopathic and osteopathic medical schools are combined, there are partnerships between the VA and 90% of U.S. medical schools. More than 70% of all U.S. practicing physicians trained at a VA facility at some time.² Currently, the VA has more than 40 different health care professional training programs under its auspices.

This educational mission is a core VA function that is enshrined in law as are VA’s other 3 core charges. According to the statute, the VA secretary shall “to the extent feasible without interfering with the medical care and treatment of veterans, develop and carry out a program of education and training of health personnel.” The primary clinical care, education, and research functions of the VA are inseparable, and none can be carried out without an adequate number of qualified staff.

Government reports and the media have identified the shortage of VA health care professionals as a major contributor to the wait times crisis of the past several years.³ Section 301 of the Veterans Access, Choice, and Accountability Act of 2014 actually requires the VA Office of Inspector General (OIG) to conduct assessments of the staffing shortages in the department. Reports from the OIG have identified 5 critical need occupations: medical officer, nurse, psychologist, physician assistant, and physical therapist.⁴

From my perspective as a medical officer, I am certain that the reason I went straight to the VA after my residency in psychiatry and have never left is my overwhelmingly positive experience as a medical student and resident. The VA had many of the best teachers in my training programs. The patients were—and still are nearly 20 years later—among the most respectful and appreciative of any I have treated.

Many VA patients considered us, even as trainees, their doctors and often asked us when we were residents whether they could “keep us,” although they knew that as former members of the military, most of us would rotate out of their lives. Yet they also knew that because of the strength of the training programs, a new young doctor would come to take care of them. Even now when the occasional angry patient says, “all you doctors care about is money,” I am proud to say that I could probably make more money in the private sector, but I choose to work at the VA.

Many of my fine colleagues in medicine, nursing, psychology, and allied health also remained at the VA after their training, inspired to provide public health to those who served and were underserved. Those who entered military medicine or the PHS had similar ideals borne of the role models who taught them in those federal institutions. One of the often unappreciated negative consequences of the VA scandal is that it may discouarge students in the health care professions from rotating through or seriously considering careers in the VA.

The VA and the military often do not receive the recognition they deserve as academic medical institutions. Some of the most renowned and accomplished faculty of prestigious medical universities also work at VA facilities. The ability to simultaneously teach gifted students, conduct cutting-edge research, and practice high-quality medicine all in a public health setting are what attracted me and many other idealistic health care professionals to the VA.

The VA, however, has taken active steps to restore its reputation as one of the best places to learn and work. Three outstanding initiatives deserve special attention. The first being a series of visits to medical schools that Carolyn M. Clancy, MD, made when she was the interim under secretary for health. Fortunately for me, she spoke at the academic affiliate of my VAMC (the University of New Mexico School of Medicine), where she talked about the excitement and rewards of VA clinical care and research.⁵

The VA Nursing Academic Partnerships (VANAP) is another initiative to promote VA as an educator and employer of health professionals. Comprised of 18 competitively selected nursing schools in the nation and the VA, VANAP’s objective is “increasing recruitment and retention of VA nurses as a result of enhanced roles in nursing education.” The New Mexico VA Health Care System, the hospital I practice at, had the honor of being awarded one of these partnerships, and I have been encouraged to see many student nurses choose the training track at the VA and express interest in employment.

According to a nurse at the Oregon Health & Science University VA partnership, “One thing I learned that I did not expect was about the wars the clients had served in. I gained a greater respect for our men and women in the service past and present…I have now an understanding of not only the physical, but also the mental and emotional effects war has on an individual.”⁶ It is important to realize that even if physicians and nurses in training do not ultimately enter the VA workforce, they still leave their educational experience with a more empathic understanding of the health care needs of veterans.

The salience of the third endeavor, however, has not been widely recognized. In March, Secretary Robert McDonald spoke at a meeting of the Association of American Medical Colleges Council of Deans. His speech traced the history of academic collaboration with the VA; acknowledged the bureaucratic, information technology, and other challenges faced by the VA and its academic affiliates; and reaffirmed the VA’s commitment to academic partnerships. He recognized the significant and lasting contributions the relationship with academic medical centers has had on the care of veterans and the community for decades. His remarks concluded with a vision of the potential the partnership has to transform health education and the delivery of care in the years to come. But perhaps the most hopeful remarks in the speech came not from Secretary McDonald but from the comments of medical students who had rotated at the San Diego VAMC, which he shared:

“The emphasis on teaching was fantastic, and far superior to most other rotations.”

“The vets were a wonderful patient population who really allowed us a great opportunity to learn.”

“The VA is the best place for medical students to work.”⁷ 

This July, medical students, residents, and fellows in almost every medical and surgical specialty will join nurses at all levels of training, undergraduate and graduate pharmacists, dentists, and allied health students to train at a VA hospital. The VA Office of Academic Affiliations (OAA), which coordinates this massive educational effort, reported that in 2015, the last year for which data are available, 123,552 health care trainees were enrolled in VA programs.¹ That’s in addition to the hundreds of health care professionals trained in the 4 branches of the armed services, including students at the Uniformed Services University of the Health Sciences and those receiving a health care education through the PHS. Federal institutions are easily the largest contributors to health care education in the nation and very likely in the world.

This mission to educate the U.S. health care workforce is not new. This year marks the 70th anniversary of the collaboration between the VA and academic affiliates across the country to ensure a highly qualified cadre of health care professionals care, not only for veterans, but also for the public. Hence, the OAA motto: To educate for VA and for the nation.

When allopathic and osteopathic medical schools are combined, there are partnerships between the VA and 90% of U.S. medical schools. More than 70% of all U.S. practicing physicians trained at a VA facility at some time.² Currently, the VA has more than 40 different health care professional training programs under its auspices.

This educational mission is a core VA function that is enshrined in law as are VA’s other 3 core charges. According to the statute, the VA secretary shall “to the extent feasible without interfering with the medical care and treatment of veterans, develop and carry out a program of education and training of health personnel.” The primary clinical care, education, and research functions of the VA are inseparable, and none can be carried out without an adequate number of qualified staff.

Government reports and the media have identified the shortage of VA health care professionals as a major contributor to the wait times crisis of the past several years.³ Section 301 of the Veterans Access, Choice, and Accountability Act of 2014 actually requires the VA Office of Inspector General (OIG) to conduct assessments of the staffing shortages in the department. Reports from the OIG have identified 5 critical need occupations: medical officer, nurse, psychologist, physician assistant, and physical therapist.⁴

From my perspective as a medical officer, I am certain that the reason I went straight to the VA after my residency in psychiatry and have never left is my overwhelmingly positive experience as a medical student and resident. The VA had many of the best teachers in my training programs. The patients were—and still are nearly 20 years later—among the most respectful and appreciative of any I have treated.

Many VA patients considered us, even as trainees, their doctors and often asked us when we were residents whether they could “keep us,” although they knew that as former members of the military, most of us would rotate out of their lives. Yet they also knew that because of the strength of the training programs, a new young doctor would come to take care of them. Even now when the occasional angry patient says, “all you doctors care about is money,” I am proud to say that I could probably make more money in the private sector, but I choose to work at the VA.

Many of my fine colleagues in medicine, nursing, psychology, and allied health also remained at the VA after their training, inspired to provide public health to those who served and were underserved. Those who entered military medicine or the PHS had similar ideals borne of the role models who taught them in those federal institutions. One of the often unappreciated negative consequences of the VA scandal is that it may discouarge students in the health care professions from rotating through or seriously considering careers in the VA.

The VA and the military often do not receive the recognition they deserve as academic medical institutions. Some of the most renowned and accomplished faculty of prestigious medical universities also work at VA facilities. The ability to simultaneously teach gifted students, conduct cutting-edge research, and practice high-quality medicine all in a public health setting are what attracted me and many other idealistic health care professionals to the VA.

The VA, however, has taken active steps to restore its reputation as one of the best places to learn and work. Three outstanding initiatives deserve special attention. The first being a series of visits to medical schools that Carolyn M. Clancy, MD, made when she was the interim under secretary for health. Fortunately for me, she spoke at the academic affiliate of my VAMC (the University of New Mexico School of Medicine), where she talked about the excitement and rewards of VA clinical care and research.⁵

The VA Nursing Academic Partnerships (VANAP) is another initiative to promote VA as an educator and employer of health professionals. Comprised of 18 competitively selected nursing schools in the nation and the VA, VANAP’s objective is “increasing recruitment and retention of VA nurses as a result of enhanced roles in nursing education.” The New Mexico VA Health Care System, the hospital I practice at, had the honor of being awarded one of these partnerships, and I have been encouraged to see many student nurses choose the training track at the VA and express interest in employment.

According to a nurse at the Oregon Health & Science University VA partnership, “One thing I learned that I did not expect was about the wars the clients had served in. I gained a greater respect for our men and women in the service past and present…I have now an understanding of not only the physical, but also the mental and emotional effects war has on an individual.”⁶ It is important to realize that even if physicians and nurses in training do not ultimately enter the VA workforce, they still leave their educational experience with a more empathic understanding of the health care needs of veterans.

The salience of the third endeavor, however, has not been widely recognized. In March, Secretary Robert McDonald spoke at a meeting of the Association of American Medical Colleges Council of Deans. His speech traced the history of academic collaboration with the VA; acknowledged the bureaucratic, information technology, and other challenges faced by the VA and its academic affiliates; and reaffirmed the VA’s commitment to academic partnerships. He recognized the significant and lasting contributions the relationship with academic medical centers has had on the care of veterans and the community for decades. His remarks concluded with a vision of the potential the partnership has to transform health education and the delivery of care in the years to come. But perhaps the most hopeful remarks in the speech came not from Secretary McDonald but from the comments of medical students who had rotated at the San Diego VAMC, which he shared:

“The emphasis on teaching was fantastic, and far superior to most other rotations.”

“The vets were a wonderful patient population who really allowed us a great opportunity to learn.”

“The VA is the best place for medical students to work.”⁷ 

This July, medical students, residents, and fellows in almost every medical and surgical specialty will join nurses at all levels of training, undergraduate and graduate pharmacists, dentists, and allied health students to train at a VA hospital. The VA Office of Academic Affiliations (OAA), which coordinates this massive educational effort, reported that in 2015, the last year for which data are available, 123,552 health care trainees were enrolled in VA programs.¹ That’s in addition to the hundreds of health care professionals trained in the 4 branches of the armed services, including students at the Uniformed Services University of the Health Sciences and those receiving a health care education through the PHS. Federal institutions are easily the largest contributors to health care education in the nation and very likely in the world.

This mission to educate the U.S. health care workforce is not new. This year marks the 70th anniversary of the collaboration between the VA and academic affiliates across the country to ensure a highly qualified cadre of health care professionals care, not only for veterans, but also for the public. Hence, the OAA motto: To educate for VA and for the nation.

When allopathic and osteopathic medical schools are combined, there are partnerships between the VA and 90% of U.S. medical schools. More than 70% of all U.S. practicing physicians trained at a VA facility at some time.² Currently, the VA has more than 40 different health care professional training programs under its auspices.

This educational mission is a core VA function that is enshrined in law as are VA’s other 3 core charges. According to the statute, the VA secretary shall “to the extent feasible without interfering with the medical care and treatment of veterans, develop and carry out a program of education and training of health personnel.” The primary clinical care, education, and research functions of the VA are inseparable, and none can be carried out without an adequate number of qualified staff.

Government reports and the media have identified the shortage of VA health care professionals as a major contributor to the wait times crisis of the past several years.³ Section 301 of the Veterans Access, Choice, and Accountability Act of 2014 actually requires the VA Office of Inspector General (OIG) to conduct assessments of the staffing shortages in the department. Reports from the OIG have identified 5 critical need occupations: medical officer, nurse, psychologist, physician assistant, and physical therapist.⁴

From my perspective as a medical officer, I am certain that the reason I went straight to the VA after my residency in psychiatry and have never left is my overwhelmingly positive experience as a medical student and resident. The VA had many of the best teachers in my training programs. The patients were—and still are nearly 20 years later—among the most respectful and appreciative of any I have treated.

Many VA patients considered us, even as trainees, their doctors and often asked us when we were residents whether they could “keep us,” although they knew that as former members of the military, most of us would rotate out of their lives. Yet they also knew that because of the strength of the training programs, a new young doctor would come to take care of them. Even now when the occasional angry patient says, “all you doctors care about is money,” I am proud to say that I could probably make more money in the private sector, but I choose to work at the VA.

Many of my fine colleagues in medicine, nursing, psychology, and allied health also remained at the VA after their training, inspired to provide public health to those who served and were underserved. Those who entered military medicine or the PHS had similar ideals borne of the role models who taught them in those federal institutions. One of the often unappreciated negative consequences of the VA scandal is that it may discouarge students in the health care professions from rotating through or seriously considering careers in the VA.

The VA and the military often do not receive the recognition they deserve as academic medical institutions. Some of the most renowned and accomplished faculty of prestigious medical universities also work at VA facilities. The ability to simultaneously teach gifted students, conduct cutting-edge research, and practice high-quality medicine all in a public health setting are what attracted me and many other idealistic health care professionals to the VA.

The VA, however, has taken active steps to restore its reputation as one of the best places to learn and work. Three outstanding initiatives deserve special attention. The first being a series of visits to medical schools that Carolyn M. Clancy, MD, made when she was the interim under secretary for health. Fortunately for me, she spoke at the academic affiliate of my VAMC (the University of New Mexico School of Medicine), where she talked about the excitement and rewards of VA clinical care and research.⁵

The VA Nursing Academic Partnerships (VANAP) is another initiative to promote VA as an educator and employer of health professionals. Comprised of 18 competitively selected nursing schools in the nation and the VA, VANAP’s objective is “increasing recruitment and retention of VA nurses as a result of enhanced roles in nursing education.” The New Mexico VA Health Care System, the hospital I practice at, had the honor of being awarded one of these partnerships, and I have been encouraged to see many student nurses choose the training track at the VA and express interest in employment.

According to a nurse at the Oregon Health & Science University VA partnership, “One thing I learned that I did not expect was about the wars the clients had served in. I gained a greater respect for our men and women in the service past and present…I have now an understanding of not only the physical, but also the mental and emotional effects war has on an individual.”⁶ It is important to realize that even if physicians and nurses in training do not ultimately enter the VA workforce, they still leave their educational experience with a more empathic understanding of the health care needs of veterans.

The salience of the third endeavor, however, has not been widely recognized. In March, Secretary Robert McDonald spoke at a meeting of the Association of American Medical Colleges Council of Deans. His speech traced the history of academic collaboration with the VA; acknowledged the bureaucratic, information technology, and other challenges faced by the VA and its academic affiliates; and reaffirmed the VA’s commitment to academic partnerships. He recognized the significant and lasting contributions the relationship with academic medical centers has had on the care of veterans and the community for decades. His remarks concluded with a vision of the potential the partnership has to transform health education and the delivery of care in the years to come. But perhaps the most hopeful remarks in the speech came not from Secretary McDonald but from the comments of medical students who had rotated at the San Diego VAMC, which he shared:

“The emphasis on teaching was fantastic, and far superior to most other rotations.”

“The vets were a wonderful patient population who really allowed us a great opportunity to learn.”

“The VA is the best place for medical students to work.”⁷ 

As young physicians, we are taught to be as objective as possible when evaluating a patient; however, cognitive biases are regularly encountered in day-to-day patient experiences and can unfortunately influence our clinical decision-making skills to be subpar.

Consider the following case: An overweight 74-year-old man with diabetes mellitus and a nonhealing ulceration on the left lower extremity presented to the emergency department for repeat evaluation. He previously had been treated by an outside dermatologist for stasis dermatitis and was being managed with compression, elevation, and lubrication of both lower extremities. Often, the initial reaction is to conclude that the patient does in fact have an ulceration associated with stasis dermatitis and changing the management strategy or performing a biopsy would not change the outcome. However, this response limits the potential to provide the patient with a thorough examination. If the patient is treated with the same management strategies that previously failed rather than delving into all the causes for nonhealing ulceration on the left lower extremity, a vital diagnosis could be missed. In this scenario, when the patient was ultimately biopsied, the diagnosis was an ulcerative squamous cell carcinoma.

These subconscious predetermined decisions regarding difficult patient encounters come from the physician’s heuristics, a process of decision-making wherein a snap judgment about a patient occurs because it is similar to prior patient encounters or a set of views from prior knowledge of the disease.^1,2

A recent article by Cohen and Burgin³ elucidated a set of cognitive biases that often are encountered in dermatology practices, including affective, anchoring, availability, and confirmation biases; zebra retreat; and Sutton’s slip.

Affective Bias

Affective bias is a process in which emotions regarding a patient interaction alter the objective prospective and reasoning of a patient. For example, consider the case of a pemphigus vulgaris patient who does not want to be on prednisone due to weight gain and persistently presents to the dermatology clinic insisting that the physician taper the dosage. To avoid the constant frustration and upsetting the patient further, the dermatologist tapers the dosage of prednisone prematurely and the patient has a flare.

Anchoring Bias

Anchoring bias occurs when initial information regarding a patient causes one to jump to a conclusion rather than developing a thorough history. An example may be if an infant presents with a mole on the nasal dorsum that the patient’s father reports has only been present for a short while. Without performing imaging studies or asking for further history, the physician decides to biopsy the lesion. The biopsy results show a neural mass, such that a nasal glioma cannot be ruled out. In this bias, magnetic resonance imaging would have been prudent prior to biopsy and premature action.

Availability Bias

Availability bias refers to a diagnosis that immediately comes to mind, as it is common or recently encountered, such as in the example presented at the beginning of this column about the patient with squamous cell carcinoma.

Confirmation Bias

Confirmation bias caters to elucidating information that confirms your own clinical suspicion as opposed to determining the true cause of the disease etiology. Consider the following example: An obese patient presents with a history of painful sores on the bilateral lower extremities. The physician asks specifically about diabetes mellitus and mobility. When the patient answers yes to poor mobility and diabetes mellitus, the physician asks questions confirming an initial suspected diagnosis of stasis dermatitis. Unfortunately, as the patient continues to get worse, it is revealed that his medication history indicates he has been taking sulfasalazine for several years, and it is eventually determined that the patient has cutaneous Crohn disease.

Zebra Retreat

This bias describes a physician’s unwillingness to consider a diagnosis because it is very obscure, even if it is correct. For example, the case of the patient described in the previous example with a diagnosis of cutaneous Crohn disease also can be considered as an example of zebra retreat. Because the clinician may rarely think of this diagnosis due to its infrequent presentation, he/she may not consider doing a biopsy or investigate further.

Sutton’s Slip

This bias describes a situation in which a physician disregards a problem because a thorough examination is not performed, which is classically noted when physicians treat their family and friends. If asked about a mole or lesion regarding its questionable nature, a dermatologist may either disregard it or not evaluate it carefully, as the person is in a casual setting.

Final Thoughts

Although there are several other types of cognitive biases, those described here show that on several occasions, dermatologists can be swayed toward an incorrect diagnosis simply because of a subconscious thought process. Often times, such as in multiple-choice examinations, initial guesses are usually the best answers, but care has to be taken when in a clinical setting. Our patients rarely are good historians and do not present in well-written question stems. The biases emphasize that dermatologists in training should keep their minds open, focus on getting a clear and concise history, and use their knowledge as a tool to derive a well thought-out answer.

As young physicians, we are taught to be as objective as possible when evaluating a patient; however, cognitive biases are regularly encountered in day-to-day patient experiences and can unfortunately influence our clinical decision-making skills to be subpar.

Consider the following case: An overweight 74-year-old man with diabetes mellitus and a nonhealing ulceration on the left lower extremity presented to the emergency department for repeat evaluation. He previously had been treated by an outside dermatologist for stasis dermatitis and was being managed with compression, elevation, and lubrication of both lower extremities. Often, the initial reaction is to conclude that the patient does in fact have an ulceration associated with stasis dermatitis and changing the management strategy or performing a biopsy would not change the outcome. However, this response limits the potential to provide the patient with a thorough examination. If the patient is treated with the same management strategies that previously failed rather than delving into all the causes for nonhealing ulceration on the left lower extremity, a vital diagnosis could be missed. In this scenario, when the patient was ultimately biopsied, the diagnosis was an ulcerative squamous cell carcinoma.

These subconscious predetermined decisions regarding difficult patient encounters come from the physician’s heuristics, a process of decision-making wherein a snap judgment about a patient occurs because it is similar to prior patient encounters or a set of views from prior knowledge of the disease.^1,2

A recent article by Cohen and Burgin³ elucidated a set of cognitive biases that often are encountered in dermatology practices, including affective, anchoring, availability, and confirmation biases; zebra retreat; and Sutton’s slip.

Affective Bias

Affective bias is a process in which emotions regarding a patient interaction alter the objective prospective and reasoning of a patient. For example, consider the case of a pemphigus vulgaris patient who does not want to be on prednisone due to weight gain and persistently presents to the dermatology clinic insisting that the physician taper the dosage. To avoid the constant frustration and upsetting the patient further, the dermatologist tapers the dosage of prednisone prematurely and the patient has a flare.

Anchoring Bias

Anchoring bias occurs when initial information regarding a patient causes one to jump to a conclusion rather than developing a thorough history. An example may be if an infant presents with a mole on the nasal dorsum that the patient’s father reports has only been present for a short while. Without performing imaging studies or asking for further history, the physician decides to biopsy the lesion. The biopsy results show a neural mass, such that a nasal glioma cannot be ruled out. In this bias, magnetic resonance imaging would have been prudent prior to biopsy and premature action.

Availability Bias

Availability bias refers to a diagnosis that immediately comes to mind, as it is common or recently encountered, such as in the example presented at the beginning of this column about the patient with squamous cell carcinoma.

Confirmation Bias

Confirmation bias caters to elucidating information that confirms your own clinical suspicion as opposed to determining the true cause of the disease etiology. Consider the following example: An obese patient presents with a history of painful sores on the bilateral lower extremities. The physician asks specifically about diabetes mellitus and mobility. When the patient answers yes to poor mobility and diabetes mellitus, the physician asks questions confirming an initial suspected diagnosis of stasis dermatitis. Unfortunately, as the patient continues to get worse, it is revealed that his medication history indicates he has been taking sulfasalazine for several years, and it is eventually determined that the patient has cutaneous Crohn disease.

Zebra Retreat

This bias describes a physician’s unwillingness to consider a diagnosis because it is very obscure, even if it is correct. For example, the case of the patient described in the previous example with a diagnosis of cutaneous Crohn disease also can be considered as an example of zebra retreat. Because the clinician may rarely think of this diagnosis due to its infrequent presentation, he/she may not consider doing a biopsy or investigate further.

Sutton’s Slip

This bias describes a situation in which a physician disregards a problem because a thorough examination is not performed, which is classically noted when physicians treat their family and friends. If asked about a mole or lesion regarding its questionable nature, a dermatologist may either disregard it or not evaluate it carefully, as the person is in a casual setting.

Final Thoughts

Although there are several other types of cognitive biases, those described here show that on several occasions, dermatologists can be swayed toward an incorrect diagnosis simply because of a subconscious thought process. Often times, such as in multiple-choice examinations, initial guesses are usually the best answers, but care has to be taken when in a clinical setting. Our patients rarely are good historians and do not present in well-written question stems. The biases emphasize that dermatologists in training should keep their minds open, focus on getting a clear and concise history, and use their knowledge as a tool to derive a well thought-out answer.

As young physicians, we are taught to be as objective as possible when evaluating a patient; however, cognitive biases are regularly encountered in day-to-day patient experiences and can unfortunately influence our clinical decision-making skills to be subpar.

Consider the following case: An overweight 74-year-old man with diabetes mellitus and a nonhealing ulceration on the left lower extremity presented to the emergency department for repeat evaluation. He previously had been treated by an outside dermatologist for stasis dermatitis and was being managed with compression, elevation, and lubrication of both lower extremities. Often, the initial reaction is to conclude that the patient does in fact have an ulceration associated with stasis dermatitis and changing the management strategy or performing a biopsy would not change the outcome. However, this response limits the potential to provide the patient with a thorough examination. If the patient is treated with the same management strategies that previously failed rather than delving into all the causes for nonhealing ulceration on the left lower extremity, a vital diagnosis could be missed. In this scenario, when the patient was ultimately biopsied, the diagnosis was an ulcerative squamous cell carcinoma.

These subconscious predetermined decisions regarding difficult patient encounters come from the physician’s heuristics, a process of decision-making wherein a snap judgment about a patient occurs because it is similar to prior patient encounters or a set of views from prior knowledge of the disease.^1,2

A recent article by Cohen and Burgin³ elucidated a set of cognitive biases that often are encountered in dermatology practices, including affective, anchoring, availability, and confirmation biases; zebra retreat; and Sutton’s slip.

Affective Bias

Affective bias is a process in which emotions regarding a patient interaction alter the objective prospective and reasoning of a patient. For example, consider the case of a pemphigus vulgaris patient who does not want to be on prednisone due to weight gain and persistently presents to the dermatology clinic insisting that the physician taper the dosage. To avoid the constant frustration and upsetting the patient further, the dermatologist tapers the dosage of prednisone prematurely and the patient has a flare.

Anchoring Bias

Anchoring bias occurs when initial information regarding a patient causes one to jump to a conclusion rather than developing a thorough history. An example may be if an infant presents with a mole on the nasal dorsum that the patient’s father reports has only been present for a short while. Without performing imaging studies or asking for further history, the physician decides to biopsy the lesion. The biopsy results show a neural mass, such that a nasal glioma cannot be ruled out. In this bias, magnetic resonance imaging would have been prudent prior to biopsy and premature action.

Availability Bias

Availability bias refers to a diagnosis that immediately comes to mind, as it is common or recently encountered, such as in the example presented at the beginning of this column about the patient with squamous cell carcinoma.

Confirmation Bias

Confirmation bias caters to elucidating information that confirms your own clinical suspicion as opposed to determining the true cause of the disease etiology. Consider the following example: An obese patient presents with a history of painful sores on the bilateral lower extremities. The physician asks specifically about diabetes mellitus and mobility. When the patient answers yes to poor mobility and diabetes mellitus, the physician asks questions confirming an initial suspected diagnosis of stasis dermatitis. Unfortunately, as the patient continues to get worse, it is revealed that his medication history indicates he has been taking sulfasalazine for several years, and it is eventually determined that the patient has cutaneous Crohn disease.

Zebra Retreat

This bias describes a physician’s unwillingness to consider a diagnosis because it is very obscure, even if it is correct. For example, the case of the patient described in the previous example with a diagnosis of cutaneous Crohn disease also can be considered as an example of zebra retreat. Because the clinician may rarely think of this diagnosis due to its infrequent presentation, he/she may not consider doing a biopsy or investigate further.

Sutton’s Slip

This bias describes a situation in which a physician disregards a problem because a thorough examination is not performed, which is classically noted when physicians treat their family and friends. If asked about a mole or lesion regarding its questionable nature, a dermatologist may either disregard it or not evaluate it carefully, as the person is in a casual setting.

Final Thoughts

Although there are several other types of cognitive biases, those described here show that on several occasions, dermatologists can be swayed toward an incorrect diagnosis simply because of a subconscious thought process. Often times, such as in multiple-choice examinations, initial guesses are usually the best answers, but care has to be taken when in a clinical setting. Our patients rarely are good historians and do not present in well-written question stems. The biases emphasize that dermatologists in training should keep their minds open, focus on getting a clear and concise history, and use their knowledge as a tool to derive a well thought-out answer.

The therapeutic alliance (interchangeably, the therapeutic relationship) is a subjective measure of the relationship between a clinician and a patient. It is an indicator of clinical trustworthiness: what a patient is referring to when she (he) expresses trust in her provider. The therapeutic alliance also is known as the working alliance, the therapeutic bond, and the helping alliance,¹ and it is an important factor in patient satisfaction ratings—the gauging parameter through which clinicians and institutions measure the quality of care they provide.²

A therapeutic alliance is essential to the delivery of psychiatric care. Itself, it can be a healing factor³ and has been linked to patients’ adherence to treatment and continuation of care.⁴ For example, psychiatric patients who perceive the therapeutic alliance more positively have:

• a better long-term health outcome after discharge
• a significantly better psychological quality of life⁵
• a better follow-up record of outpatient care after inpatient discharge^4,6
• better adherence to prescribed treatment⁷
• a reduced likelihood of relapse and readmission.⁶

Patient satisfaction is an indirect measure of the therapeutic alliance; many variables of the therapeutic relationship can affect that satisfaction. In this article, we call those variables patient factors and delivery factors; our aim, using the example of 2 hypothetical cases, is to highlight their importance in patients’ perception of the therapeutic alliance they have with providers.

CASE Paranoid delusions lead to termination of care
Mr. D, age 21, unmarried, unemployed, and with no medical or psychiatric history, is transferred from the medical floor to the inpatient psychiatric unit after coming to the hospital’s emergency room (ER) with a report of chest pain. Workup on the medical floor was negative for a serious cardiac event.

On questioning, Mr. D tells the team that his chest pain is caused by National Security Agency (NSA) satellites “locking” onto his heart and causing veins in his heart to “pop.”

Mr. D agrees to be transferred to the psychiatric unit. Once there, however, he refuses to take the psychotropic medications that have been prescribed or to comply with the balance of the treatment protocol. He is adamant about the influence of NSA satellites, and requests daily imaging to locate evidence of the path of the satellite tracking device that he claims is inside his body.

The treatment team repeatedly refuses to comply with Mr. D’s demand for imaging. He becomes angry and says that he does not think he is getting proper care because the nature of his problem is medical, not psychiatric.

Mr. D repeatedly asserts that he will not take any of the psychotropic medications that have been prescribed for him and will not attend follow-up appointments with the psychiatry team because he does not need treatment. He accuses the treatment team of conspiring with the NSA and causing his chest pain.

Mr. D asks to be discharged.

Patient factors: Unmodifiable and static
As Mr. D’s case exemplifies, patient factors are a set of elements, intrinsic to a given patient, that affect that patient’s perceptions independent of the quality of the care delivered. Included among patient factors are personal sociodemographic and psychopathological characteristics. These patient factors influence the therapeutic relationship in many ways.

Sociodemographics. It has been reported that patients of minority heritage and those who are male, young, and unmarried tend to be less satisfied with medical treatment in general and with psychiatric inpatient treatment in particular.^8,9 Females and older patients, on the other hand, are more likely to be satisfied with the perceived delivery of care and the therapeutic alliance.^8-10

Psychopathology affects patients’ perception of the delivery of care and the therapeutic alliance. Patients who are highly distressed psychologically and those who suffer chronic psychiatric illness, for example, tend to perceive themselves as having benefitted less from treatment than healthier counterparts.^9,11 Such patients also tend to see their therapeutic outcome in a much less favorable light.^11,12 Patients with borderline personality disorder and antisocial personality disorder^12-14 and those hospitalized involuntarily⁸ tend to (1) be less satisfied with their therapeutic outcome and (2) see the therapeutic alliance less favorably compared with those who do not have these psychopathologies.

CASE Denied a blanket, she feels like a 'burden'
Ms. X, age 34, married and a homemaker, has a history of bipolar I disorder. She brings herself to the ER complaining of depression and suicidal ideation.

After Ms. X is seen by the psychiatry consult service in the ER, she reports that she feels frustrated and angry and thinks that the hospital’s physicians do not really want to help her. She states that she felt that the ER staff “dismissed” her, in part because she spent 4 hours in the ER waiting room before she was given a bed.

Ms. X says that, once she was placed in a room, she felt that the nursing staff and medical assistants ignored her because they did not give her the extra blanket she requested. She said she was cold as a result, while she waited to see the psychiatrist and the ER physician.

Ms. X states that she came to the ER seeking help because she felt depressed and thought that no one cared about her. Coming to the hospital made her feel worse, after all, she said, because there she has been treated like she is a burden, much like she is treated at home.

Delivery factors: Amenable to change
These mutable elements of the therapeutic alliance are dependent on the quality of the care, as they were in Ms. X’s case; they can be changed. Included among delivery factors is the quality of the relationship between provider and patient—that is, how the psychiatrist and the nursing staff relate to the patient.

Perceptions are key. Delivery factors rank as one of the most important elements that influence the patient’s perception of the therapeutic alliance.^15,16 Given the objectives of psychiatric treatment—to relieve psychiatric symptoms, improve patient functioning, and alleviate psychological distress—it is no wonder that delivery factors play an important role in the perception of the therapeutic alliance: The quality of the provider−patient relationship is the axis around which treatment takes place. This relationship constantly ranks high on surveys of what is important to patients¹⁵—especially in an inpatient psychiatric setting.

Attitudes are modifiable. From the treating psychiatrist to nursing and ancillary staffs, all team members need to express attitudes and behaviors that reflect positively on the patient.¹⁷ Behaviors such as involving the patient fully in therapeutic decision-making; exuding an attitude of caring, equanimity, empathy, sincerity, and respect; and listening to the patient’s concerns can go a long way to improving the therapeutic relationship. Displaying such attitudes and behaviors also help improve the larger vision of psychiatric intervention: to bring about positive therapeutic changes.

Summing up
Ratings of the therapeutic alliance are the currency of patient satisfaction. The value of this therapeutic currency is affected by delivery factors, which are adjustable, and patient factors, which are not. Taken together, however, both types of factors are the foundation of patient satisfaction and the therapeutic alliance.

The therapeutic alliance (interchangeably, the therapeutic relationship) is a subjective measure of the relationship between a clinician and a patient. It is an indicator of clinical trustworthiness: what a patient is referring to when she (he) expresses trust in her provider. The therapeutic alliance also is known as the working alliance, the therapeutic bond, and the helping alliance,¹ and it is an important factor in patient satisfaction ratings—the gauging parameter through which clinicians and institutions measure the quality of care they provide.²

A therapeutic alliance is essential to the delivery of psychiatric care. Itself, it can be a healing factor³ and has been linked to patients’ adherence to treatment and continuation of care.⁴ For example, psychiatric patients who perceive the therapeutic alliance more positively have:

• a better long-term health outcome after discharge
• a significantly better psychological quality of life⁵
• a better follow-up record of outpatient care after inpatient discharge^4,6
• better adherence to prescribed treatment⁷
• a reduced likelihood of relapse and readmission.⁶

Patient satisfaction is an indirect measure of the therapeutic alliance; many variables of the therapeutic relationship can affect that satisfaction. In this article, we call those variables patient factors and delivery factors; our aim, using the example of 2 hypothetical cases, is to highlight their importance in patients’ perception of the therapeutic alliance they have with providers.

CASE Paranoid delusions lead to termination of care
Mr. D, age 21, unmarried, unemployed, and with no medical or psychiatric history, is transferred from the medical floor to the inpatient psychiatric unit after coming to the hospital’s emergency room (ER) with a report of chest pain. Workup on the medical floor was negative for a serious cardiac event.

On questioning, Mr. D tells the team that his chest pain is caused by National Security Agency (NSA) satellites “locking” onto his heart and causing veins in his heart to “pop.”

Mr. D agrees to be transferred to the psychiatric unit. Once there, however, he refuses to take the psychotropic medications that have been prescribed or to comply with the balance of the treatment protocol. He is adamant about the influence of NSA satellites, and requests daily imaging to locate evidence of the path of the satellite tracking device that he claims is inside his body.

The treatment team repeatedly refuses to comply with Mr. D’s demand for imaging. He becomes angry and says that he does not think he is getting proper care because the nature of his problem is medical, not psychiatric.

Mr. D repeatedly asserts that he will not take any of the psychotropic medications that have been prescribed for him and will not attend follow-up appointments with the psychiatry team because he does not need treatment. He accuses the treatment team of conspiring with the NSA and causing his chest pain.

Mr. D asks to be discharged.

Patient factors: Unmodifiable and static
As Mr. D’s case exemplifies, patient factors are a set of elements, intrinsic to a given patient, that affect that patient’s perceptions independent of the quality of the care delivered. Included among patient factors are personal sociodemographic and psychopathological characteristics. These patient factors influence the therapeutic relationship in many ways.

Sociodemographics. It has been reported that patients of minority heritage and those who are male, young, and unmarried tend to be less satisfied with medical treatment in general and with psychiatric inpatient treatment in particular.^8,9 Females and older patients, on the other hand, are more likely to be satisfied with the perceived delivery of care and the therapeutic alliance.^8-10

Psychopathology affects patients’ perception of the delivery of care and the therapeutic alliance. Patients who are highly distressed psychologically and those who suffer chronic psychiatric illness, for example, tend to perceive themselves as having benefitted less from treatment than healthier counterparts.^9,11 Such patients also tend to see their therapeutic outcome in a much less favorable light.^11,12 Patients with borderline personality disorder and antisocial personality disorder^12-14 and those hospitalized involuntarily⁸ tend to (1) be less satisfied with their therapeutic outcome and (2) see the therapeutic alliance less favorably compared with those who do not have these psychopathologies.

CASE Denied a blanket, she feels like a 'burden'
Ms. X, age 34, married and a homemaker, has a history of bipolar I disorder. She brings herself to the ER complaining of depression and suicidal ideation.

After Ms. X is seen by the psychiatry consult service in the ER, she reports that she feels frustrated and angry and thinks that the hospital’s physicians do not really want to help her. She states that she felt that the ER staff “dismissed” her, in part because she spent 4 hours in the ER waiting room before she was given a bed.

Ms. X says that, once she was placed in a room, she felt that the nursing staff and medical assistants ignored her because they did not give her the extra blanket she requested. She said she was cold as a result, while she waited to see the psychiatrist and the ER physician.

Ms. X states that she came to the ER seeking help because she felt depressed and thought that no one cared about her. Coming to the hospital made her feel worse, after all, she said, because there she has been treated like she is a burden, much like she is treated at home.

Delivery factors: Amenable to change
These mutable elements of the therapeutic alliance are dependent on the quality of the care, as they were in Ms. X’s case; they can be changed. Included among delivery factors is the quality of the relationship between provider and patient—that is, how the psychiatrist and the nursing staff relate to the patient.

Perceptions are key. Delivery factors rank as one of the most important elements that influence the patient’s perception of the therapeutic alliance.^15,16 Given the objectives of psychiatric treatment—to relieve psychiatric symptoms, improve patient functioning, and alleviate psychological distress—it is no wonder that delivery factors play an important role in the perception of the therapeutic alliance: The quality of the provider−patient relationship is the axis around which treatment takes place. This relationship constantly ranks high on surveys of what is important to patients¹⁵—especially in an inpatient psychiatric setting.

Attitudes are modifiable. From the treating psychiatrist to nursing and ancillary staffs, all team members need to express attitudes and behaviors that reflect positively on the patient.¹⁷ Behaviors such as involving the patient fully in therapeutic decision-making; exuding an attitude of caring, equanimity, empathy, sincerity, and respect; and listening to the patient’s concerns can go a long way to improving the therapeutic relationship. Displaying such attitudes and behaviors also help improve the larger vision of psychiatric intervention: to bring about positive therapeutic changes.

Summing up
Ratings of the therapeutic alliance are the currency of patient satisfaction. The value of this therapeutic currency is affected by delivery factors, which are adjustable, and patient factors, which are not. Taken together, however, both types of factors are the foundation of patient satisfaction and the therapeutic alliance.

The therapeutic alliance (interchangeably, the therapeutic relationship) is a subjective measure of the relationship between a clinician and a patient. It is an indicator of clinical trustworthiness: what a patient is referring to when she (he) expresses trust in her provider. The therapeutic alliance also is known as the working alliance, the therapeutic bond, and the helping alliance,¹ and it is an important factor in patient satisfaction ratings—the gauging parameter through which clinicians and institutions measure the quality of care they provide.²

A therapeutic alliance is essential to the delivery of psychiatric care. Itself, it can be a healing factor³ and has been linked to patients’ adherence to treatment and continuation of care.⁴ For example, psychiatric patients who perceive the therapeutic alliance more positively have:

• a better long-term health outcome after discharge
• a significantly better psychological quality of life⁵
• a better follow-up record of outpatient care after inpatient discharge^4,6
• better adherence to prescribed treatment⁷
• a reduced likelihood of relapse and readmission.⁶

Patient satisfaction is an indirect measure of the therapeutic alliance; many variables of the therapeutic relationship can affect that satisfaction. In this article, we call those variables patient factors and delivery factors; our aim, using the example of 2 hypothetical cases, is to highlight their importance in patients’ perception of the therapeutic alliance they have with providers.

CASE Paranoid delusions lead to termination of care
Mr. D, age 21, unmarried, unemployed, and with no medical or psychiatric history, is transferred from the medical floor to the inpatient psychiatric unit after coming to the hospital’s emergency room (ER) with a report of chest pain. Workup on the medical floor was negative for a serious cardiac event.

On questioning, Mr. D tells the team that his chest pain is caused by National Security Agency (NSA) satellites “locking” onto his heart and causing veins in his heart to “pop.”

Mr. D agrees to be transferred to the psychiatric unit. Once there, however, he refuses to take the psychotropic medications that have been prescribed or to comply with the balance of the treatment protocol. He is adamant about the influence of NSA satellites, and requests daily imaging to locate evidence of the path of the satellite tracking device that he claims is inside his body.

The treatment team repeatedly refuses to comply with Mr. D’s demand for imaging. He becomes angry and says that he does not think he is getting proper care because the nature of his problem is medical, not psychiatric.

Mr. D repeatedly asserts that he will not take any of the psychotropic medications that have been prescribed for him and will not attend follow-up appointments with the psychiatry team because he does not need treatment. He accuses the treatment team of conspiring with the NSA and causing his chest pain.

Mr. D asks to be discharged.

Patient factors: Unmodifiable and static
As Mr. D’s case exemplifies, patient factors are a set of elements, intrinsic to a given patient, that affect that patient’s perceptions independent of the quality of the care delivered. Included among patient factors are personal sociodemographic and psychopathological characteristics. These patient factors influence the therapeutic relationship in many ways.

Sociodemographics. It has been reported that patients of minority heritage and those who are male, young, and unmarried tend to be less satisfied with medical treatment in general and with psychiatric inpatient treatment in particular.^8,9 Females and older patients, on the other hand, are more likely to be satisfied with the perceived delivery of care and the therapeutic alliance.^8-10

Psychopathology affects patients’ perception of the delivery of care and the therapeutic alliance. Patients who are highly distressed psychologically and those who suffer chronic psychiatric illness, for example, tend to perceive themselves as having benefitted less from treatment than healthier counterparts.^9,11 Such patients also tend to see their therapeutic outcome in a much less favorable light.^11,12 Patients with borderline personality disorder and antisocial personality disorder^12-14 and those hospitalized involuntarily⁸ tend to (1) be less satisfied with their therapeutic outcome and (2) see the therapeutic alliance less favorably compared with those who do not have these psychopathologies.

CASE Denied a blanket, she feels like a 'burden'
Ms. X, age 34, married and a homemaker, has a history of bipolar I disorder. She brings herself to the ER complaining of depression and suicidal ideation.

After Ms. X is seen by the psychiatry consult service in the ER, she reports that she feels frustrated and angry and thinks that the hospital’s physicians do not really want to help her. She states that she felt that the ER staff “dismissed” her, in part because she spent 4 hours in the ER waiting room before she was given a bed.

Ms. X says that, once she was placed in a room, she felt that the nursing staff and medical assistants ignored her because they did not give her the extra blanket she requested. She said she was cold as a result, while she waited to see the psychiatrist and the ER physician.

Ms. X states that she came to the ER seeking help because she felt depressed and thought that no one cared about her. Coming to the hospital made her feel worse, after all, she said, because there she has been treated like she is a burden, much like she is treated at home.

Delivery factors: Amenable to change
These mutable elements of the therapeutic alliance are dependent on the quality of the care, as they were in Ms. X’s case; they can be changed. Included among delivery factors is the quality of the relationship between provider and patient—that is, how the psychiatrist and the nursing staff relate to the patient.

Perceptions are key. Delivery factors rank as one of the most important elements that influence the patient’s perception of the therapeutic alliance.^15,16 Given the objectives of psychiatric treatment—to relieve psychiatric symptoms, improve patient functioning, and alleviate psychological distress—it is no wonder that delivery factors play an important role in the perception of the therapeutic alliance: The quality of the provider−patient relationship is the axis around which treatment takes place. This relationship constantly ranks high on surveys of what is important to patients¹⁵—especially in an inpatient psychiatric setting.

Attitudes are modifiable. From the treating psychiatrist to nursing and ancillary staffs, all team members need to express attitudes and behaviors that reflect positively on the patient.¹⁷ Behaviors such as involving the patient fully in therapeutic decision-making; exuding an attitude of caring, equanimity, empathy, sincerity, and respect; and listening to the patient’s concerns can go a long way to improving the therapeutic relationship. Displaying such attitudes and behaviors also help improve the larger vision of psychiatric intervention: to bring about positive therapeutic changes.

Summing up
Ratings of the therapeutic alliance are the currency of patient satisfaction. The value of this therapeutic currency is affected by delivery factors, which are adjustable, and patient factors, which are not. Taken together, however, both types of factors are the foundation of patient satisfaction and the therapeutic alliance.

The primary cosmetic procedures that dermatology residents will perform or assist in performing during their training are soft-tissue augmentation, botulinum toxin injections, chemical peels, and laser therapy. Because complications can occur from these procedures, it is important for residents to learn how to prevent, identify, and manage them for optimal patient outcomes. In part 1 of this 2-part series, soft-tissue augmentation and botulinum toxin injections are discussed. Chemical peels and laser therapy will be addressed in part 2.

Soft-Tissue Augmentation

Soft-tissue fillers include those that are made from collagen (bovine or human), hyaluronic acid (HA), poly-L-lactic acid, calcium hydroxylapatite, silicone, and polymethylmethacrylate. In general, acute complications of soft-tissue filler injections include erythema, swelling, and bruising.^1-3 Patients who take blood thinners or supplements (eg, vitamin E, ginseng, garlic, ginger) should be asked to discontinue use 1 week prior to the procedure. Patients who take blood thinners also should be counseled to expect some bruising. Prior to injection, the skin should be thoroughly cleansed to avoid introducing skin bacteria into the injection site and to reduce infection risk. Postinjection erythema may be related to mast cell activation, which is temporary and should resolve after a few days.^1-3

If you find yourself injecting the filler too superficially, you may notice that the skin begins to take on a blue-gray hue^1-3 that is known as the Tyndall effect and can be prevented by injecting the filler at the proper level. For example, collagen-based fillers should be placed at the mid dermis, thicker HA fillers should be placed in the deep dermis, and calcium hydroxylapatite should be placed at the junction of the dermis and subcutaneous tissue. Polymethylmethacrylate and poly-L-lactic acid should both be placed subdermally.^1-3

The gravest immediate complications associated with soft-tissue filler injections are occlusion of the central retinal artery and/or skin necrosis.^1-4 Residents should never inject filler to the glabella or to the nose.^1-3 Injections at these sites are sometimes performed but should only be performed by experienced dermatologists. The perioral and tear trough regions also are high-risk injection areas that require a high degree of experience and should only be injected with proper supervision by an experienced dermatologist.^1-3 Residents generally can avoid these complications, though not with a 100% guarantee, by avoiding injections in high-risk areas, aspirating to check for blood, and slowly injecting a small amount of filler into the treatment area.^1-3 A consensus statement on management of injection-induced necrosis advises to apply a nitropaste ointment 2% to the treatment site or administer an oral aspirin if the patient develops severe pain; vision loss; or acute skin discoloration, especially blanching.⁴ For HA-based fillers, at least 200 U of hyaluronidase should be injected. It has been suggested that saline can be injected to flush out calcium hydroxylapatite fillers.³ Warm compresses should be placed on the involved area. Following these interventions, any patient with vision loss or orbital pain should immediately undergo ophthalmologic evaluation.³ The most important intervention occurs in the first 24 hours.^3,4 After 24 hours, careful wound care, oral anticoagulants, and hyperbaric oxygen therapy have been suggested as management options.³

There are 2 major chronic complications of soft-tissue filler injection, including delayed-onset infection, which occurs 2 weeks or more postinjection, and granuloma formation.^1-3 Chronic low-grade infection at the injection site may be indicative of biofilm formation. If an HA filler was used, it should be dissolved with hyaluronidase to help break up the biofilm nidus.³ A course of oral antibiotics also may be indicated.^1-3 Intralesional steroids may be used but only after antibiotics have been administered. A biofilm that develops from more permanent fillers may be more difficult to manage. Atypical mycobacterial infections have been known to develop at injection sites, which should be considered in refractory cases.^1-3,5

Calcium hydroxylapatite, polymethylmethacrylate, and silicone can stimulate chronic immune system activation, which makes them more prone to granuloma formation.^1-3 Once infection is ruled out, granulomas may be treated with intralesional steroids, surgical excision (if the results would be cosmetically acceptable), laser therapy, or potentially local injection of an immunosuppressant (eg, methotrexate, 5-fluorouracil).³

Botulinum Toxin Injections

Patients who are pregnant, lactating, or have neuromuscular disease are not candidates for botulinum toxin injections. There also is a risk that patients taking calcium channel blockers or aminoglycoside antibiotics may experience potentiated effects of the botulinum toxin.⁶

Patients should be informed that a postinjection headache may occur and should be treated with over-the-counter medications.⁶ Complication-free botulinum toxin procedures depend heavily on the physician’s knowledge of facial anatomy.^1,6 The diagrams provided by Hirsch and Stier¹ offer an excellent guide on where to place the injections. Brow droop, eyelid ptosis, and “Spock brow” (eyebrows that are overarched) largely can be avoided by proper injection point placement. A Spock brow may be corrected by injecting the lateral upper forehead with a few units to correct the exaggerated arch.^6,7 For eyelid ptosis, apraclonidine 0.05% drops (1–2 drops 3 times daily) should be used until the ptosis resolves.⁶ Phenylephrine hydrochloride drops may be used should a patient have a documented sensitivity to apraclonidine but should not be used in a patient with acute angle-closure glaucoma or aneurysms.⁶

Final Thoughts

Learning to perform soft-tissue augmentation and botulinum toxin injections can be a satisfying and fun part of dermatology residency. Preventing, identifying, and managing any complications that may occur is an integral part of performing these procedures.

The primary cosmetic procedures that dermatology residents will perform or assist in performing during their training are soft-tissue augmentation, botulinum toxin injections, chemical peels, and laser therapy. Because complications can occur from these procedures, it is important for residents to learn how to prevent, identify, and manage them for optimal patient outcomes. In part 1 of this 2-part series, soft-tissue augmentation and botulinum toxin injections are discussed. Chemical peels and laser therapy will be addressed in part 2.

Soft-Tissue Augmentation

Soft-tissue fillers include those that are made from collagen (bovine or human), hyaluronic acid (HA), poly-L-lactic acid, calcium hydroxylapatite, silicone, and polymethylmethacrylate. In general, acute complications of soft-tissue filler injections include erythema, swelling, and bruising.^1-3 Patients who take blood thinners or supplements (eg, vitamin E, ginseng, garlic, ginger) should be asked to discontinue use 1 week prior to the procedure. Patients who take blood thinners also should be counseled to expect some bruising. Prior to injection, the skin should be thoroughly cleansed to avoid introducing skin bacteria into the injection site and to reduce infection risk. Postinjection erythema may be related to mast cell activation, which is temporary and should resolve after a few days.^1-3

If you find yourself injecting the filler too superficially, you may notice that the skin begins to take on a blue-gray hue^1-3 that is known as the Tyndall effect and can be prevented by injecting the filler at the proper level. For example, collagen-based fillers should be placed at the mid dermis, thicker HA fillers should be placed in the deep dermis, and calcium hydroxylapatite should be placed at the junction of the dermis and subcutaneous tissue. Polymethylmethacrylate and poly-L-lactic acid should both be placed subdermally.^1-3

The gravest immediate complications associated with soft-tissue filler injections are occlusion of the central retinal artery and/or skin necrosis.^1-4 Residents should never inject filler to the glabella or to the nose.^1-3 Injections at these sites are sometimes performed but should only be performed by experienced dermatologists. The perioral and tear trough regions also are high-risk injection areas that require a high degree of experience and should only be injected with proper supervision by an experienced dermatologist.^1-3 Residents generally can avoid these complications, though not with a 100% guarantee, by avoiding injections in high-risk areas, aspirating to check for blood, and slowly injecting a small amount of filler into the treatment area.^1-3 A consensus statement on management of injection-induced necrosis advises to apply a nitropaste ointment 2% to the treatment site or administer an oral aspirin if the patient develops severe pain; vision loss; or acute skin discoloration, especially blanching.⁴ For HA-based fillers, at least 200 U of hyaluronidase should be injected. It has been suggested that saline can be injected to flush out calcium hydroxylapatite fillers.³ Warm compresses should be placed on the involved area. Following these interventions, any patient with vision loss or orbital pain should immediately undergo ophthalmologic evaluation.³ The most important intervention occurs in the first 24 hours.^3,4 After 24 hours, careful wound care, oral anticoagulants, and hyperbaric oxygen therapy have been suggested as management options.³

There are 2 major chronic complications of soft-tissue filler injection, including delayed-onset infection, which occurs 2 weeks or more postinjection, and granuloma formation.^1-3 Chronic low-grade infection at the injection site may be indicative of biofilm formation. If an HA filler was used, it should be dissolved with hyaluronidase to help break up the biofilm nidus.³ A course of oral antibiotics also may be indicated.^1-3 Intralesional steroids may be used but only after antibiotics have been administered. A biofilm that develops from more permanent fillers may be more difficult to manage. Atypical mycobacterial infections have been known to develop at injection sites, which should be considered in refractory cases.^1-3,5

Calcium hydroxylapatite, polymethylmethacrylate, and silicone can stimulate chronic immune system activation, which makes them more prone to granuloma formation.^1-3 Once infection is ruled out, granulomas may be treated with intralesional steroids, surgical excision (if the results would be cosmetically acceptable), laser therapy, or potentially local injection of an immunosuppressant (eg, methotrexate, 5-fluorouracil).³

Botulinum Toxin Injections

Patients who are pregnant, lactating, or have neuromuscular disease are not candidates for botulinum toxin injections. There also is a risk that patients taking calcium channel blockers or aminoglycoside antibiotics may experience potentiated effects of the botulinum toxin.⁶

Patients should be informed that a postinjection headache may occur and should be treated with over-the-counter medications.⁶ Complication-free botulinum toxin procedures depend heavily on the physician’s knowledge of facial anatomy.^1,6 The diagrams provided by Hirsch and Stier¹ offer an excellent guide on where to place the injections. Brow droop, eyelid ptosis, and “Spock brow” (eyebrows that are overarched) largely can be avoided by proper injection point placement. A Spock brow may be corrected by injecting the lateral upper forehead with a few units to correct the exaggerated arch.^6,7 For eyelid ptosis, apraclonidine 0.05% drops (1–2 drops 3 times daily) should be used until the ptosis resolves.⁶ Phenylephrine hydrochloride drops may be used should a patient have a documented sensitivity to apraclonidine but should not be used in a patient with acute angle-closure glaucoma or aneurysms.⁶

Final Thoughts

Learning to perform soft-tissue augmentation and botulinum toxin injections can be a satisfying and fun part of dermatology residency. Preventing, identifying, and managing any complications that may occur is an integral part of performing these procedures.

The primary cosmetic procedures that dermatology residents will perform or assist in performing during their training are soft-tissue augmentation, botulinum toxin injections, chemical peels, and laser therapy. Because complications can occur from these procedures, it is important for residents to learn how to prevent, identify, and manage them for optimal patient outcomes. In part 1 of this 2-part series, soft-tissue augmentation and botulinum toxin injections are discussed. Chemical peels and laser therapy will be addressed in part 2.

Soft-Tissue Augmentation

Soft-tissue fillers include those that are made from collagen (bovine or human), hyaluronic acid (HA), poly-L-lactic acid, calcium hydroxylapatite, silicone, and polymethylmethacrylate. In general, acute complications of soft-tissue filler injections include erythema, swelling, and bruising.^1-3 Patients who take blood thinners or supplements (eg, vitamin E, ginseng, garlic, ginger) should be asked to discontinue use 1 week prior to the procedure. Patients who take blood thinners also should be counseled to expect some bruising. Prior to injection, the skin should be thoroughly cleansed to avoid introducing skin bacteria into the injection site and to reduce infection risk. Postinjection erythema may be related to mast cell activation, which is temporary and should resolve after a few days.^1-3

If you find yourself injecting the filler too superficially, you may notice that the skin begins to take on a blue-gray hue^1-3 that is known as the Tyndall effect and can be prevented by injecting the filler at the proper level. For example, collagen-based fillers should be placed at the mid dermis, thicker HA fillers should be placed in the deep dermis, and calcium hydroxylapatite should be placed at the junction of the dermis and subcutaneous tissue. Polymethylmethacrylate and poly-L-lactic acid should both be placed subdermally.^1-3

The gravest immediate complications associated with soft-tissue filler injections are occlusion of the central retinal artery and/or skin necrosis.^1-4 Residents should never inject filler to the glabella or to the nose.^1-3 Injections at these sites are sometimes performed but should only be performed by experienced dermatologists. The perioral and tear trough regions also are high-risk injection areas that require a high degree of experience and should only be injected with proper supervision by an experienced dermatologist.^1-3 Residents generally can avoid these complications, though not with a 100% guarantee, by avoiding injections in high-risk areas, aspirating to check for blood, and slowly injecting a small amount of filler into the treatment area.^1-3 A consensus statement on management of injection-induced necrosis advises to apply a nitropaste ointment 2% to the treatment site or administer an oral aspirin if the patient develops severe pain; vision loss; or acute skin discoloration, especially blanching.⁴ For HA-based fillers, at least 200 U of hyaluronidase should be injected. It has been suggested that saline can be injected to flush out calcium hydroxylapatite fillers.³ Warm compresses should be placed on the involved area. Following these interventions, any patient with vision loss or orbital pain should immediately undergo ophthalmologic evaluation.³ The most important intervention occurs in the first 24 hours.^3,4 After 24 hours, careful wound care, oral anticoagulants, and hyperbaric oxygen therapy have been suggested as management options.³

There are 2 major chronic complications of soft-tissue filler injection, including delayed-onset infection, which occurs 2 weeks or more postinjection, and granuloma formation.^1-3 Chronic low-grade infection at the injection site may be indicative of biofilm formation. If an HA filler was used, it should be dissolved with hyaluronidase to help break up the biofilm nidus.³ A course of oral antibiotics also may be indicated.^1-3 Intralesional steroids may be used but only after antibiotics have been administered. A biofilm that develops from more permanent fillers may be more difficult to manage. Atypical mycobacterial infections have been known to develop at injection sites, which should be considered in refractory cases.^1-3,5

Calcium hydroxylapatite, polymethylmethacrylate, and silicone can stimulate chronic immune system activation, which makes them more prone to granuloma formation.^1-3 Once infection is ruled out, granulomas may be treated with intralesional steroids, surgical excision (if the results would be cosmetically acceptable), laser therapy, or potentially local injection of an immunosuppressant (eg, methotrexate, 5-fluorouracil).³

Botulinum Toxin Injections

Patients who are pregnant, lactating, or have neuromuscular disease are not candidates for botulinum toxin injections. There also is a risk that patients taking calcium channel blockers or aminoglycoside antibiotics may experience potentiated effects of the botulinum toxin.⁶

Patients should be informed that a postinjection headache may occur and should be treated with over-the-counter medications.⁶ Complication-free botulinum toxin procedures depend heavily on the physician’s knowledge of facial anatomy.^1,6 The diagrams provided by Hirsch and Stier¹ offer an excellent guide on where to place the injections. Brow droop, eyelid ptosis, and “Spock brow” (eyebrows that are overarched) largely can be avoided by proper injection point placement. A Spock brow may be corrected by injecting the lateral upper forehead with a few units to correct the exaggerated arch.^6,7 For eyelid ptosis, apraclonidine 0.05% drops (1–2 drops 3 times daily) should be used until the ptosis resolves.⁶ Phenylephrine hydrochloride drops may be used should a patient have a documented sensitivity to apraclonidine but should not be used in a patient with acute angle-closure glaucoma or aneurysms.⁶

Final Thoughts

Learning to perform soft-tissue augmentation and botulinum toxin injections can be a satisfying and fun part of dermatology residency. Preventing, identifying, and managing any complications that may occur is an integral part of performing these procedures.

Developing a high-efficiency operating room (OR) is both a challenging and rewarding goal for any healthcare system. The OR is traditionally a high-cost/high-revenue environment¹ and operative efficacy has been correlated with low complication rates and surgical success.² An efficient OR is one that maximizes utilization while providing safe, reproducible, cost-effective, high-quality care. Total joint arthroplasty (TJA) has occupied the center stage for OR efficiency research, in part due to increasing demands from our aging population³ and economic pressures related to high implant costs, decreased reimbursement, and competition for market shares when OR time and space are limited.

A PubMed search on OR efficiency in TJA shows a disproportionately high focus on surgical technique, such as use of patient-specific instrumentation (PSI), computer-assisted surgery (CAS), minimally invasive surgery, and closure with barbed suture. In a retrospective review of 352 TKA patients who had PSI vs conventional instrumentation, DeHaan and colleagues⁴ found that PSI was associated with significantly decreased operative and room turnover times (20.4 minutes and 6.4 minutes, respectively). In another prospective multicenter study, Mont and colleagues⁵ showed a reduction in surgical time by 8.90 min for navigated total knee arthroplasty (TKA) performed with single-use instruments, cutting blocks, and trials. Other investigators compared PSI to CAS in TKA and found PSI to be 1.45 times more profitable than CAS, with 3 PSI cases performed in an 8-hour OR day compared to 2 CAS cases.⁶

There is no question that improved surgical technique can enhance OR efficiency. However, this model, while promising, is difficult to implement on a wide scale due to surgeon preferences, vendor limitations, and added costs related to the advanced preoperative imaging studies, manufacturing of the custom guides, and maintenance of navigation equipment. In addition, while interventions such as the use of barbed suture have the potential for speeding closure time, the time saved (4.7 minutes in one randomized trial)⁷ may not be enough to affect major utilization differences per OR per day. These technologies are also frequently employed by high-volume surgeons with high-volume teams and institutions.

Ideally, we need investment in the human capital and a collective change in work cultures to produce high-quality, well-choreographed, easily reproducible routines. An efficient OR requires the synchronous involvement of a large team of individuals, including hospital administrators, surgery schedulers, surgeons, anesthesiologists, preoperative holding area staff, OR nurses, surgical attendants, sterile processing personnel, and recovery room nurses. Case schedulers should match allocated block time with time required for surgery based on the historical performance of the individual surgeon, preferably scheduling similar cases on the same day. Preoperative work-up and medical clearance should be completed prior to scheduling to avoid last-minute cancellations. Patient reminders and accommodations for those traveling from long distances can further minimize late arrivals. Prompt initiation of the perioperative clinical pathway upon a patient’s check-in is important. The surgical site should be marked and the anesthesia plan confirmed upon arrival in the preoperative holding area. Necessary products need to be ready and/or administrated in time for transfer to the OR. These include prophylactic antibiotics, coagulation factors (eg, tranexamic acid), and blood products as indicated. Spinal anesthesia, regional nerve blocks, and intravenous (IV) lines should be completed before transfer to the OR. A “block room” close to the OR can allow concurrent induction of anesthesia and has been shown to increase the number of surgical cases performed during a regular workday.⁸ Hair clipping within the surgical site and pre-scrubbing of the operative extremity should also be performed prior to transfer to the OR in order to minimize micro-organisms and dispersal of loose hair onto the sterile field.

Upon arrival of the patient to the OR, instrument tables based on the surgeon preference cards should be opened, instrument count and implant templating completed, necessary imaging displayed, and OR staff ready with specific responsibilities assigned to each member. Small and colleagues⁹ showed that using dedicated orthopedic staff familiar with the surgical routine decreased operative time by 19 minutes per procedure, or 1.25 hours for a surgeon performing 4 primary TJAs per day. Practices such as routine placement of a urinary catheter should be seriously scrutinized. In a randomized prospective study of patients undergoing total hip arthroplasty under spinal anesthesia, Miller and colleagues¹⁰ found no benefit for indwelling catheters in preventing urinary retention. In another randomized prospective study, Huang and colleagues¹¹ found the prevalence of urinary tract infections was significantly higher in TJA patients who received indwelling urinary catheters.

A scrub nurse familiar with the instruments, their assembly, and the sequence of events can ensure efficient surgical flow. The scrub nurse needs to anticipate missing or defective tools and call for them, ideally before the incision is made. Direct comparison studies are needed to assess the efficacy of routine intraoperative imaging vs commercially available universal cup alignment guides or clinical examinations in determining acceptable component positioning and limb length. Following component implantation and before wound closure, the circulating nurse should initiate the process of acquisition of a recovery room bed, make sure dressing supplies and necessary equipment are available, and call for surgical attendants. Lack of surgical attendants, delayed transfer from the OR table to hospital bed, and prolonged acquisition of a recovery room bed have been identified as major OR inefficiencies in a retrospective study by Attarian and colleagues.¹²

In summary, time is the OR’s most valuable resource.¹³ We believe that a consistent, almost automated attitude to the above procedures decreases variability and improves efficiency. By providing clear communication of the surgical needs with the team, having consistent anesthesia and nursing staff, implementing consistent perioperative protocols, and insuring that all necessary instruments and modalities are available prior to starting the procedure, we were able to sustainably increase OR throughput in a large teaching hospital.^9,14 This process, however, requires constant review to identify and eliminate new gaps, with each member of the team sharing a frank desire to improve. In this regard, hospital administrators share the duty to facilitate the implementation of any necessary changes, allocation of needed resources, and rewarding good effort, which could ultimately increase staff satisfaction and retention. Because efficiency is the ratio of benefits (eg, revenue, safety, etc.) to investment (eg, implant costs, wages, etc.), raises the question: what would be the effect of transitioning from hourly-wage to a salary-based system for key support staff? Unlike hourly-wage personnel, who have no incentive for productivity, a salaried employee assigned to a high-efficiency OR will inherently strive for improvement, employing higher organizational skills to accomplish a common goal. To our knowledge, there is no published data on this topic.

Developing a high-efficiency operating room (OR) is both a challenging and rewarding goal for any healthcare system. The OR is traditionally a high-cost/high-revenue environment¹ and operative efficacy has been correlated with low complication rates and surgical success.² An efficient OR is one that maximizes utilization while providing safe, reproducible, cost-effective, high-quality care. Total joint arthroplasty (TJA) has occupied the center stage for OR efficiency research, in part due to increasing demands from our aging population³ and economic pressures related to high implant costs, decreased reimbursement, and competition for market shares when OR time and space are limited.

A PubMed search on OR efficiency in TJA shows a disproportionately high focus on surgical technique, such as use of patient-specific instrumentation (PSI), computer-assisted surgery (CAS), minimally invasive surgery, and closure with barbed suture. In a retrospective review of 352 TKA patients who had PSI vs conventional instrumentation, DeHaan and colleagues⁴ found that PSI was associated with significantly decreased operative and room turnover times (20.4 minutes and 6.4 minutes, respectively). In another prospective multicenter study, Mont and colleagues⁵ showed a reduction in surgical time by 8.90 min for navigated total knee arthroplasty (TKA) performed with single-use instruments, cutting blocks, and trials. Other investigators compared PSI to CAS in TKA and found PSI to be 1.45 times more profitable than CAS, with 3 PSI cases performed in an 8-hour OR day compared to 2 CAS cases.⁶

There is no question that improved surgical technique can enhance OR efficiency. However, this model, while promising, is difficult to implement on a wide scale due to surgeon preferences, vendor limitations, and added costs related to the advanced preoperative imaging studies, manufacturing of the custom guides, and maintenance of navigation equipment. In addition, while interventions such as the use of barbed suture have the potential for speeding closure time, the time saved (4.7 minutes in one randomized trial)⁷ may not be enough to affect major utilization differences per OR per day. These technologies are also frequently employed by high-volume surgeons with high-volume teams and institutions.

Ideally, we need investment in the human capital and a collective change in work cultures to produce high-quality, well-choreographed, easily reproducible routines. An efficient OR requires the synchronous involvement of a large team of individuals, including hospital administrators, surgery schedulers, surgeons, anesthesiologists, preoperative holding area staff, OR nurses, surgical attendants, sterile processing personnel, and recovery room nurses. Case schedulers should match allocated block time with time required for surgery based on the historical performance of the individual surgeon, preferably scheduling similar cases on the same day. Preoperative work-up and medical clearance should be completed prior to scheduling to avoid last-minute cancellations. Patient reminders and accommodations for those traveling from long distances can further minimize late arrivals. Prompt initiation of the perioperative clinical pathway upon a patient’s check-in is important. The surgical site should be marked and the anesthesia plan confirmed upon arrival in the preoperative holding area. Necessary products need to be ready and/or administrated in time for transfer to the OR. These include prophylactic antibiotics, coagulation factors (eg, tranexamic acid), and blood products as indicated. Spinal anesthesia, regional nerve blocks, and intravenous (IV) lines should be completed before transfer to the OR. A “block room” close to the OR can allow concurrent induction of anesthesia and has been shown to increase the number of surgical cases performed during a regular workday.⁸ Hair clipping within the surgical site and pre-scrubbing of the operative extremity should also be performed prior to transfer to the OR in order to minimize micro-organisms and dispersal of loose hair onto the sterile field.

Upon arrival of the patient to the OR, instrument tables based on the surgeon preference cards should be opened, instrument count and implant templating completed, necessary imaging displayed, and OR staff ready with specific responsibilities assigned to each member. Small and colleagues⁹ showed that using dedicated orthopedic staff familiar with the surgical routine decreased operative time by 19 minutes per procedure, or 1.25 hours for a surgeon performing 4 primary TJAs per day. Practices such as routine placement of a urinary catheter should be seriously scrutinized. In a randomized prospective study of patients undergoing total hip arthroplasty under spinal anesthesia, Miller and colleagues¹⁰ found no benefit for indwelling catheters in preventing urinary retention. In another randomized prospective study, Huang and colleagues¹¹ found the prevalence of urinary tract infections was significantly higher in TJA patients who received indwelling urinary catheters.

A scrub nurse familiar with the instruments, their assembly, and the sequence of events can ensure efficient surgical flow. The scrub nurse needs to anticipate missing or defective tools and call for them, ideally before the incision is made. Direct comparison studies are needed to assess the efficacy of routine intraoperative imaging vs commercially available universal cup alignment guides or clinical examinations in determining acceptable component positioning and limb length. Following component implantation and before wound closure, the circulating nurse should initiate the process of acquisition of a recovery room bed, make sure dressing supplies and necessary equipment are available, and call for surgical attendants. Lack of surgical attendants, delayed transfer from the OR table to hospital bed, and prolonged acquisition of a recovery room bed have been identified as major OR inefficiencies in a retrospective study by Attarian and colleagues.¹²

In summary, time is the OR’s most valuable resource.¹³ We believe that a consistent, almost automated attitude to the above procedures decreases variability and improves efficiency. By providing clear communication of the surgical needs with the team, having consistent anesthesia and nursing staff, implementing consistent perioperative protocols, and insuring that all necessary instruments and modalities are available prior to starting the procedure, we were able to sustainably increase OR throughput in a large teaching hospital.^9,14 This process, however, requires constant review to identify and eliminate new gaps, with each member of the team sharing a frank desire to improve. In this regard, hospital administrators share the duty to facilitate the implementation of any necessary changes, allocation of needed resources, and rewarding good effort, which could ultimately increase staff satisfaction and retention. Because efficiency is the ratio of benefits (eg, revenue, safety, etc.) to investment (eg, implant costs, wages, etc.), raises the question: what would be the effect of transitioning from hourly-wage to a salary-based system for key support staff? Unlike hourly-wage personnel, who have no incentive for productivity, a salaried employee assigned to a high-efficiency OR will inherently strive for improvement, employing higher organizational skills to accomplish a common goal. To our knowledge, there is no published data on this topic.

Developing a high-efficiency operating room (OR) is both a challenging and rewarding goal for any healthcare system. The OR is traditionally a high-cost/high-revenue environment¹ and operative efficacy has been correlated with low complication rates and surgical success.² An efficient OR is one that maximizes utilization while providing safe, reproducible, cost-effective, high-quality care. Total joint arthroplasty (TJA) has occupied the center stage for OR efficiency research, in part due to increasing demands from our aging population³ and economic pressures related to high implant costs, decreased reimbursement, and competition for market shares when OR time and space are limited.

A PubMed search on OR efficiency in TJA shows a disproportionately high focus on surgical technique, such as use of patient-specific instrumentation (PSI), computer-assisted surgery (CAS), minimally invasive surgery, and closure with barbed suture. In a retrospective review of 352 TKA patients who had PSI vs conventional instrumentation, DeHaan and colleagues⁴ found that PSI was associated with significantly decreased operative and room turnover times (20.4 minutes and 6.4 minutes, respectively). In another prospective multicenter study, Mont and colleagues⁵ showed a reduction in surgical time by 8.90 min for navigated total knee arthroplasty (TKA) performed with single-use instruments, cutting blocks, and trials. Other investigators compared PSI to CAS in TKA and found PSI to be 1.45 times more profitable than CAS, with 3 PSI cases performed in an 8-hour OR day compared to 2 CAS cases.⁶

There is no question that improved surgical technique can enhance OR efficiency. However, this model, while promising, is difficult to implement on a wide scale due to surgeon preferences, vendor limitations, and added costs related to the advanced preoperative imaging studies, manufacturing of the custom guides, and maintenance of navigation equipment. In addition, while interventions such as the use of barbed suture have the potential for speeding closure time, the time saved (4.7 minutes in one randomized trial)⁷ may not be enough to affect major utilization differences per OR per day. These technologies are also frequently employed by high-volume surgeons with high-volume teams and institutions.

Ideally, we need investment in the human capital and a collective change in work cultures to produce high-quality, well-choreographed, easily reproducible routines. An efficient OR requires the synchronous involvement of a large team of individuals, including hospital administrators, surgery schedulers, surgeons, anesthesiologists, preoperative holding area staff, OR nurses, surgical attendants, sterile processing personnel, and recovery room nurses. Case schedulers should match allocated block time with time required for surgery based on the historical performance of the individual surgeon, preferably scheduling similar cases on the same day. Preoperative work-up and medical clearance should be completed prior to scheduling to avoid last-minute cancellations. Patient reminders and accommodations for those traveling from long distances can further minimize late arrivals. Prompt initiation of the perioperative clinical pathway upon a patient’s check-in is important. The surgical site should be marked and the anesthesia plan confirmed upon arrival in the preoperative holding area. Necessary products need to be ready and/or administrated in time for transfer to the OR. These include prophylactic antibiotics, coagulation factors (eg, tranexamic acid), and blood products as indicated. Spinal anesthesia, regional nerve blocks, and intravenous (IV) lines should be completed before transfer to the OR. A “block room” close to the OR can allow concurrent induction of anesthesia and has been shown to increase the number of surgical cases performed during a regular workday.⁸ Hair clipping within the surgical site and pre-scrubbing of the operative extremity should also be performed prior to transfer to the OR in order to minimize micro-organisms and dispersal of loose hair onto the sterile field.

Upon arrival of the patient to the OR, instrument tables based on the surgeon preference cards should be opened, instrument count and implant templating completed, necessary imaging displayed, and OR staff ready with specific responsibilities assigned to each member. Small and colleagues⁹ showed that using dedicated orthopedic staff familiar with the surgical routine decreased operative time by 19 minutes per procedure, or 1.25 hours for a surgeon performing 4 primary TJAs per day. Practices such as routine placement of a urinary catheter should be seriously scrutinized. In a randomized prospective study of patients undergoing total hip arthroplasty under spinal anesthesia, Miller and colleagues¹⁰ found no benefit for indwelling catheters in preventing urinary retention. In another randomized prospective study, Huang and colleagues¹¹ found the prevalence of urinary tract infections was significantly higher in TJA patients who received indwelling urinary catheters.

A scrub nurse familiar with the instruments, their assembly, and the sequence of events can ensure efficient surgical flow. The scrub nurse needs to anticipate missing or defective tools and call for them, ideally before the incision is made. Direct comparison studies are needed to assess the efficacy of routine intraoperative imaging vs commercially available universal cup alignment guides or clinical examinations in determining acceptable component positioning and limb length. Following component implantation and before wound closure, the circulating nurse should initiate the process of acquisition of a recovery room bed, make sure dressing supplies and necessary equipment are available, and call for surgical attendants. Lack of surgical attendants, delayed transfer from the OR table to hospital bed, and prolonged acquisition of a recovery room bed have been identified as major OR inefficiencies in a retrospective study by Attarian and colleagues.¹²

In summary, time is the OR’s most valuable resource.¹³ We believe that a consistent, almost automated attitude to the above procedures decreases variability and improves efficiency. By providing clear communication of the surgical needs with the team, having consistent anesthesia and nursing staff, implementing consistent perioperative protocols, and insuring that all necessary instruments and modalities are available prior to starting the procedure, we were able to sustainably increase OR throughput in a large teaching hospital.^9,14 This process, however, requires constant review to identify and eliminate new gaps, with each member of the team sharing a frank desire to improve. In this regard, hospital administrators share the duty to facilitate the implementation of any necessary changes, allocation of needed resources, and rewarding good effort, which could ultimately increase staff satisfaction and retention. Because efficiency is the ratio of benefits (eg, revenue, safety, etc.) to investment (eg, implant costs, wages, etc.), raises the question: what would be the effect of transitioning from hourly-wage to a salary-based system for key support staff? Unlike hourly-wage personnel, who have no incentive for productivity, a salaried employee assigned to a high-efficiency OR will inherently strive for improvement, employing higher organizational skills to accomplish a common goal. To our knowledge, there is no published data on this topic.

As a resident in psychiatry, I am being trained in the art of diagnosis, treatment, and prevention of mental illness and emotional problems. As part of my training, research and scholarly activities are encouraged—reminding us that clinical medicine is always evolving and that it is every physician’s duty to be at the forefront of advancements in medical science.

Last year, I worked in the clinical trial industry under a seasoned principal investigator. I learned several lessons from my time with him and in the industry. Here, I present these lessons as a starting point for residents who are looking to gain experience or contemplating a career as an expert trialist or principal investigator.

Lesson 1: Know the lingo
To make the transition from physician to principal investigator go more smoothly, I recommend taking the time to learn the language of the industry. The good news? Clinical trials involve patients who have a medical history and take medications, which you are well acquainted with. In addition to medical jargon, the industry has developed its own distinctive terminology and abbreviations: adverse drug reaction (ADR), good clinical practice (GCP), contract research organization (CRO), and more.

Don’t stop there, however. I recommend that you read FDA research guidelines and guidelines of the International Conference on Harmonisation of Good Clinical Practice (ICH-GCP) to be familiar with the ethics and standard regulations of the industry.

Lesson 2: When in doubt, refer to the Protocol
Every clinical trial has a manual, so to speak, known as the Study Protocol, which outlines approved methods of performing diagnostic tests and procedures; provides information on the study timeline; and specifies patient inclusion and exclusion criteria. This document ensures conformity across all study sites, helps prevent errors, limits bias, and answers questions that might come up during the study. It’s worth noting that, in my experience, many of the questions about exclusionary medications arise when psychiatric drugs are involved.

Lesson 3: Document. Document. And document.
The golden rule in clinical practice and research is: “If it isn’t documented, it didn’t happen.” (Recall what I said about reading FDA and ICH-GCP guidelines to learn about regulations.) Documentation of all study-related activities must be meticulous. At any time, your documents might be subject to external or internal audit, conducted to preserve conformity to the protocol and maintain patient safety. Improper documentation can delay, even invalidate, your research.

Lesson 4: Remember that advertising is an art
The real work begins when your site is ready to accept patients. To fill the study, patients need to be aware that you are recruiting participants. A good starting point is to inform likely candidates from your existing patient population about any studies from which they might benefit.

Most times, however, recruiting among your patients is not enough to meet necessary enrollment numbers. You will have to advertise the study to the general public. Advertisements must target the specific patient population, informing them of the study but, at the same time, not be coercive or make false promises. The advertisements must be approved by the study’s institutional review board, which is responsible for protecting the rights and welfare of study participants.

Advertising can be tricky. If an advertisement is too vague, you will get a huge response, causing time and resources to be spent screening patients—most of whom might not be suitable for the study. If an advertisement is too specific, on the other hand, the response might be poor or none at all.

Advertising is its own industry. It might be best to hire an advertising expert who can help you decide on the selection of media (radio, television, print, digital) and can design a campaign that best suits your needs. If you decide to hire a professional, I recommend close collaboration with him (her), to help him understand the medical nature of the study.

Related Resources

• ClinicalTrials.gov. About clinical studies. https://clinicaltrials.gov/ct2/about-studies.

• U.S. Food and Drug Administration. Clinical trials and human subject protection. http://www.fda.gov/ScienceResearch/SpecialTopics/RunningClinicalTrials/default.htm.

• ICH GCP. International Conference on Harmonisation of technical requirements for registration of pharmaceuticals for human use. http://ichgcp.net/.

As a resident in psychiatry, I am being trained in the art of diagnosis, treatment, and prevention of mental illness and emotional problems. As part of my training, research and scholarly activities are encouraged—reminding us that clinical medicine is always evolving and that it is every physician’s duty to be at the forefront of advancements in medical science.

Last year, I worked in the clinical trial industry under a seasoned principal investigator. I learned several lessons from my time with him and in the industry. Here, I present these lessons as a starting point for residents who are looking to gain experience or contemplating a career as an expert trialist or principal investigator.

Lesson 1: Know the lingo
To make the transition from physician to principal investigator go more smoothly, I recommend taking the time to learn the language of the industry. The good news? Clinical trials involve patients who have a medical history and take medications, which you are well acquainted with. In addition to medical jargon, the industry has developed its own distinctive terminology and abbreviations: adverse drug reaction (ADR), good clinical practice (GCP), contract research organization (CRO), and more.

Don’t stop there, however. I recommend that you read FDA research guidelines and guidelines of the International Conference on Harmonisation of Good Clinical Practice (ICH-GCP) to be familiar with the ethics and standard regulations of the industry.

Lesson 2: When in doubt, refer to the Protocol
Every clinical trial has a manual, so to speak, known as the Study Protocol, which outlines approved methods of performing diagnostic tests and procedures; provides information on the study timeline; and specifies patient inclusion and exclusion criteria. This document ensures conformity across all study sites, helps prevent errors, limits bias, and answers questions that might come up during the study. It’s worth noting that, in my experience, many of the questions about exclusionary medications arise when psychiatric drugs are involved.

Lesson 3: Document. Document. And document.
The golden rule in clinical practice and research is: “If it isn’t documented, it didn’t happen.” (Recall what I said about reading FDA and ICH-GCP guidelines to learn about regulations.) Documentation of all study-related activities must be meticulous. At any time, your documents might be subject to external or internal audit, conducted to preserve conformity to the protocol and maintain patient safety. Improper documentation can delay, even invalidate, your research.

Lesson 4: Remember that advertising is an art
The real work begins when your site is ready to accept patients. To fill the study, patients need to be aware that you are recruiting participants. A good starting point is to inform likely candidates from your existing patient population about any studies from which they might benefit.

Most times, however, recruiting among your patients is not enough to meet necessary enrollment numbers. You will have to advertise the study to the general public. Advertisements must target the specific patient population, informing them of the study but, at the same time, not be coercive or make false promises. The advertisements must be approved by the study’s institutional review board, which is responsible for protecting the rights and welfare of study participants.

Advertising can be tricky. If an advertisement is too vague, you will get a huge response, causing time and resources to be spent screening patients—most of whom might not be suitable for the study. If an advertisement is too specific, on the other hand, the response might be poor or none at all.

Advertising is its own industry. It might be best to hire an advertising expert who can help you decide on the selection of media (radio, television, print, digital) and can design a campaign that best suits your needs. If you decide to hire a professional, I recommend close collaboration with him (her), to help him understand the medical nature of the study.

Related Resources

• ClinicalTrials.gov. About clinical studies. https://clinicaltrials.gov/ct2/about-studies.

• U.S. Food and Drug Administration. Clinical trials and human subject protection. http://www.fda.gov/ScienceResearch/SpecialTopics/RunningClinicalTrials/default.htm.

• ICH GCP. International Conference on Harmonisation of technical requirements for registration of pharmaceuticals for human use. http://ichgcp.net/.

As a resident in psychiatry, I am being trained in the art of diagnosis, treatment, and prevention of mental illness and emotional problems. As part of my training, research and scholarly activities are encouraged—reminding us that clinical medicine is always evolving and that it is every physician’s duty to be at the forefront of advancements in medical science.

Last year, I worked in the clinical trial industry under a seasoned principal investigator. I learned several lessons from my time with him and in the industry. Here, I present these lessons as a starting point for residents who are looking to gain experience or contemplating a career as an expert trialist or principal investigator.

Lesson 1: Know the lingo
To make the transition from physician to principal investigator go more smoothly, I recommend taking the time to learn the language of the industry. The good news? Clinical trials involve patients who have a medical history and take medications, which you are well acquainted with. In addition to medical jargon, the industry has developed its own distinctive terminology and abbreviations: adverse drug reaction (ADR), good clinical practice (GCP), contract research organization (CRO), and more.

Don’t stop there, however. I recommend that you read FDA research guidelines and guidelines of the International Conference on Harmonisation of Good Clinical Practice (ICH-GCP) to be familiar with the ethics and standard regulations of the industry.

Lesson 2: When in doubt, refer to the Protocol
Every clinical trial has a manual, so to speak, known as the Study Protocol, which outlines approved methods of performing diagnostic tests and procedures; provides information on the study timeline; and specifies patient inclusion and exclusion criteria. This document ensures conformity across all study sites, helps prevent errors, limits bias, and answers questions that might come up during the study. It’s worth noting that, in my experience, many of the questions about exclusionary medications arise when psychiatric drugs are involved.

Lesson 3: Document. Document. And document.
The golden rule in clinical practice and research is: “If it isn’t documented, it didn’t happen.” (Recall what I said about reading FDA and ICH-GCP guidelines to learn about regulations.) Documentation of all study-related activities must be meticulous. At any time, your documents might be subject to external or internal audit, conducted to preserve conformity to the protocol and maintain patient safety. Improper documentation can delay, even invalidate, your research.

Lesson 4: Remember that advertising is an art
The real work begins when your site is ready to accept patients. To fill the study, patients need to be aware that you are recruiting participants. A good starting point is to inform likely candidates from your existing patient population about any studies from which they might benefit.

Most times, however, recruiting among your patients is not enough to meet necessary enrollment numbers. You will have to advertise the study to the general public. Advertisements must target the specific patient population, informing them of the study but, at the same time, not be coercive or make false promises. The advertisements must be approved by the study’s institutional review board, which is responsible for protecting the rights and welfare of study participants.

Advertising can be tricky. If an advertisement is too vague, you will get a huge response, causing time and resources to be spent screening patients—most of whom might not be suitable for the study. If an advertisement is too specific, on the other hand, the response might be poor or none at all.

Advertising is its own industry. It might be best to hire an advertising expert who can help you decide on the selection of media (radio, television, print, digital) and can design a campaign that best suits your needs. If you decide to hire a professional, I recommend close collaboration with him (her), to help him understand the medical nature of the study.

Related Resources

• ClinicalTrials.gov. About clinical studies. https://clinicaltrials.gov/ct2/about-studies.

• U.S. Food and Drug Administration. Clinical trials and human subject protection. http://www.fda.gov/ScienceResearch/SpecialTopics/RunningClinicalTrials/default.htm.

• ICH GCP. International Conference on Harmonisation of technical requirements for registration of pharmaceuticals for human use. http://ichgcp.net/.

The measure of a country’s greatness, Mahatma Gandhi said, should be based on how well it cares for its most vulnerable. Recently, I had the opportunity to work with members of a vulnerable population: men and women who have a mental illness and languish in jails and prisons around the country. My experience was eye-opening and heartbreaking.

Widespread incarceration of the mentally ill in a developed country such as the United States should be a national embarrassment. But this tragedy, which has reached an epidemic level, has been effectively shut out of the national conversation.

The problem has grown, and is enormous
By the estimate of the U.S. Department of Justice, more than one-half of people incarcerated in the United States are mentally ill and approximately 20% suffer from a serious mental illness.^1,2 In fact, there are now 3 times as many mentally ill people in jail and prison as there are occupying psychiatric beds in hospitals.³ These numbers represent a considerable increase over the past 6 decades, and can be attributed to 2 major factors:

• A program of deinstitutionalization set in motion by the federal government in the 1950s called for shuttering of state psychiatric facilities around the country. This was a period of renewed national discourse on civil rights; for many people, the practice of institutionalization was considered a violation of civil rights. (Coincidentally, chlorpromazine was introduced about this time, and many experts believed that the drug would revolutionize outpatient management of psychiatric disorders.)
• More recently, heavy criminal penalties have been attached to convictions for possession and distribution of illegal substances—part of the government’s “war on drugs.”

As a consequence of these programs and policies, the United States has come full circle—routinely incarcerating the mentally ill as it did in the early 19th century, before reforms were initiated in response to the lobbying efforts of activist Dorothea Dix and her contemporaries.

My distressing, eye-opening experience
The time I spent with the incarcerated mentally ill was limited to a 6-month period at a county jail during residency. Yet the contrast between services provided to this population and those that are available to people in the community was immediately evident—and stark. The sheer number of adults in jails and prisons who require mental health care is such that the ratio of patients to psychiatrists, psychologists, and other mental health clinicians is shockingly skewed.

It does not take years of experience to figure out that a brief interview with an 18-year-old who is being jailed for the first time, has never seen a psychiatrist, and suffers panic attacks (or hallucinations, or suicidal thoughts) is a less-than-ideal clinical situation. Making that situation even more hazardous is that inmates have a high risk of suicide, particularly in the first 24 to 48 hours of incarceration.⁴

Other ethical issues arose during my stint in the correctional system: My patients frequently would be charged with prison-rule violations (there is evidence that mentally ill inmates are more likely to be charged with such violations²); on many such occasions, they would be placed in solitary confinement (“the hole”), a practice the United Nations has called “cruel, inhuman, and degrading: for the mentally ill⁵ and that, in turn, exacerbates the inmate’s psychiatric illness.^6-11

Last, there are restrictions on the types of formulations of medications that can be prescribed, involuntary treatment, and other critical aspects of care that make the experience of providing care in this system frustrating for mental health providers.

Are there solutions?
One way to tackle this crisis might be to insert more psychiatrists and psychologists into the correctional system. A more sensible approach, however, would be to tackle the root cause and divert the mentally ill away from incarceration and into treatment—moving from a model of retribution and incapacitation to one of rehabilitation. For example:

• Several counties nationwide have adopted diversion programs that include so-called mental health courts and drug courts, with encouraging results¹²
• Police departments are establishing Crisis Intervention Teams
• Assisted outpatient treatment programs are growing in popularity.

Far more needs to be done, however. In the absence of a national debate on the problem of the incarcerated mentally ill, there is real risk that this population will continue to be ignored and that our mental health care infrastructure will remain inadequate for meeting their need for services.

The measure of a country’s greatness, Mahatma Gandhi said, should be based on how well it cares for its most vulnerable. Recently, I had the opportunity to work with members of a vulnerable population: men and women who have a mental illness and languish in jails and prisons around the country. My experience was eye-opening and heartbreaking.

Widespread incarceration of the mentally ill in a developed country such as the United States should be a national embarrassment. But this tragedy, which has reached an epidemic level, has been effectively shut out of the national conversation.

The problem has grown, and is enormous
By the estimate of the U.S. Department of Justice, more than one-half of people incarcerated in the United States are mentally ill and approximately 20% suffer from a serious mental illness.^1,2 In fact, there are now 3 times as many mentally ill people in jail and prison as there are occupying psychiatric beds in hospitals.³ These numbers represent a considerable increase over the past 6 decades, and can be attributed to 2 major factors:

• A program of deinstitutionalization set in motion by the federal government in the 1950s called for shuttering of state psychiatric facilities around the country. This was a period of renewed national discourse on civil rights; for many people, the practice of institutionalization was considered a violation of civil rights. (Coincidentally, chlorpromazine was introduced about this time, and many experts believed that the drug would revolutionize outpatient management of psychiatric disorders.)
• More recently, heavy criminal penalties have been attached to convictions for possession and distribution of illegal substances—part of the government’s “war on drugs.”

As a consequence of these programs and policies, the United States has come full circle—routinely incarcerating the mentally ill as it did in the early 19th century, before reforms were initiated in response to the lobbying efforts of activist Dorothea Dix and her contemporaries.

My distressing, eye-opening experience
The time I spent with the incarcerated mentally ill was limited to a 6-month period at a county jail during residency. Yet the contrast between services provided to this population and those that are available to people in the community was immediately evident—and stark. The sheer number of adults in jails and prisons who require mental health care is such that the ratio of patients to psychiatrists, psychologists, and other mental health clinicians is shockingly skewed.

It does not take years of experience to figure out that a brief interview with an 18-year-old who is being jailed for the first time, has never seen a psychiatrist, and suffers panic attacks (or hallucinations, or suicidal thoughts) is a less-than-ideal clinical situation. Making that situation even more hazardous is that inmates have a high risk of suicide, particularly in the first 24 to 48 hours of incarceration.⁴

Other ethical issues arose during my stint in the correctional system: My patients frequently would be charged with prison-rule violations (there is evidence that mentally ill inmates are more likely to be charged with such violations²); on many such occasions, they would be placed in solitary confinement (“the hole”), a practice the United Nations has called “cruel, inhuman, and degrading: for the mentally ill⁵ and that, in turn, exacerbates the inmate’s psychiatric illness.^6-11

Last, there are restrictions on the types of formulations of medications that can be prescribed, involuntary treatment, and other critical aspects of care that make the experience of providing care in this system frustrating for mental health providers.

Are there solutions?
One way to tackle this crisis might be to insert more psychiatrists and psychologists into the correctional system. A more sensible approach, however, would be to tackle the root cause and divert the mentally ill away from incarceration and into treatment—moving from a model of retribution and incapacitation to one of rehabilitation. For example:

• Several counties nationwide have adopted diversion programs that include so-called mental health courts and drug courts, with encouraging results¹²
• Police departments are establishing Crisis Intervention Teams
• Assisted outpatient treatment programs are growing in popularity.

Far more needs to be done, however. In the absence of a national debate on the problem of the incarcerated mentally ill, there is real risk that this population will continue to be ignored and that our mental health care infrastructure will remain inadequate for meeting their need for services.

The measure of a country’s greatness, Mahatma Gandhi said, should be based on how well it cares for its most vulnerable. Recently, I had the opportunity to work with members of a vulnerable population: men and women who have a mental illness and languish in jails and prisons around the country. My experience was eye-opening and heartbreaking.

Widespread incarceration of the mentally ill in a developed country such as the United States should be a national embarrassment. But this tragedy, which has reached an epidemic level, has been effectively shut out of the national conversation.

The problem has grown, and is enormous
By the estimate of the U.S. Department of Justice, more than one-half of people incarcerated in the United States are mentally ill and approximately 20% suffer from a serious mental illness.^1,2 In fact, there are now 3 times as many mentally ill people in jail and prison as there are occupying psychiatric beds in hospitals.³ These numbers represent a considerable increase over the past 6 decades, and can be attributed to 2 major factors:

• A program of deinstitutionalization set in motion by the federal government in the 1950s called for shuttering of state psychiatric facilities around the country. This was a period of renewed national discourse on civil rights; for many people, the practice of institutionalization was considered a violation of civil rights. (Coincidentally, chlorpromazine was introduced about this time, and many experts believed that the drug would revolutionize outpatient management of psychiatric disorders.)
• More recently, heavy criminal penalties have been attached to convictions for possession and distribution of illegal substances—part of the government’s “war on drugs.”

As a consequence of these programs and policies, the United States has come full circle—routinely incarcerating the mentally ill as it did in the early 19th century, before reforms were initiated in response to the lobbying efforts of activist Dorothea Dix and her contemporaries.

My distressing, eye-opening experience
The time I spent with the incarcerated mentally ill was limited to a 6-month period at a county jail during residency. Yet the contrast between services provided to this population and those that are available to people in the community was immediately evident—and stark. The sheer number of adults in jails and prisons who require mental health care is such that the ratio of patients to psychiatrists, psychologists, and other mental health clinicians is shockingly skewed.

It does not take years of experience to figure out that a brief interview with an 18-year-old who is being jailed for the first time, has never seen a psychiatrist, and suffers panic attacks (or hallucinations, or suicidal thoughts) is a less-than-ideal clinical situation. Making that situation even more hazardous is that inmates have a high risk of suicide, particularly in the first 24 to 48 hours of incarceration.⁴

Other ethical issues arose during my stint in the correctional system: My patients frequently would be charged with prison-rule violations (there is evidence that mentally ill inmates are more likely to be charged with such violations²); on many such occasions, they would be placed in solitary confinement (“the hole”), a practice the United Nations has called “cruel, inhuman, and degrading: for the mentally ill⁵ and that, in turn, exacerbates the inmate’s psychiatric illness.^6-11

Last, there are restrictions on the types of formulations of medications that can be prescribed, involuntary treatment, and other critical aspects of care that make the experience of providing care in this system frustrating for mental health providers.

Are there solutions?
One way to tackle this crisis might be to insert more psychiatrists and psychologists into the correctional system. A more sensible approach, however, would be to tackle the root cause and divert the mentally ill away from incarceration and into treatment—moving from a model of retribution and incapacitation to one of rehabilitation. For example:

• Several counties nationwide have adopted diversion programs that include so-called mental health courts and drug courts, with encouraging results¹²
• Police departments are establishing Crisis Intervention Teams
• Assisted outpatient treatment programs are growing in popularity.

Far more needs to be done, however. In the absence of a national debate on the problem of the incarcerated mentally ill, there is real risk that this population will continue to be ignored and that our mental health care infrastructure will remain inadequate for meeting their need for services.

Vitiligo is a common, asymptomatic, acquired depigmentation disorder that is caused by an unknown etiology. Lesions appear as sharply demarcated, depigmented macules and patches that are scattered symmetrically or unsymmetrically over the body. The presentation can be delineated based on the segmental or nonsegmental nature of the disease. According to the revised classification/nomenclature of vitiligo,¹ the disorder can be classified as nonsegmental, segmental, mixed, or unclassified. The pathogenesis of the vitiligo disease process is due to multiple modalities that contribute to melanocyte loss. Theories for melanocyte destruction include but are not limited to autoimmunity, biochemicals, epidermal cytokines, increased hydrogen peroxide and free radicals, and humoral and cellular immune alteration.^2,3

Despite its long history, the most frustrating aspect of the vitiligo disease process remains its treatment due to limited efficacy, frequent application of topicals, and the need for high-potency steroids. Medical therapies usually are the first line of treatment and are most effective with few side effects for bilateral nonsegmental or evolving vitiligo.² Some of the primary therapies with the highest efficacies appear to be calcipotriene and psoralen plus UVA, psoralen plus UVA as monotherapy, excimer laser, narrowband UVB, oral steroids, 8-methoxypsoralen, tacrolimus, and topical steroids.⁴ The theory is that these treatments would be successful if the patient had active melanocytes in the external root sheath that would be able to repigment a patch of vitiligo.⁵ Hence, it would be more difficult to treat areas such as the dorsal aspect of the fingers and toes because they lack hair-bearing areas with melanocytes.⁶ The alternative approach to treating vitiligo patches would be surgical intervention techniques, as they provide melanocytic cells to a previously depigmented area.^3,5 The focus of this article is to evaluate the efficacy and appropriate use of some of the surgical procedures that can be used in the treatment of vitiligo patients.

Candidate Selection

First, vitiligo patients for whom first-line treatment with medical therapies has failed are candidates for surgical techniques. The second vital component is to clinically confirm the diagnosis of vitiligo as opposed to other genetic, infectious, or autoimmune causes of pigment loss. Lastly, the vitiligo patch should be stable. A stable vitiligo patch does not continue to progress and is no longer responsive to topical medications that are meant to repigment for a discernible period of time.⁷

Classification of Disease Stage

To classify the stage of vitiligo prior to surgical intervention, Gauthier⁸ created a basic grading system: grade I, with partial depletion of epidermal melanocytes in a vitiligo patch that responds to repigmentation in a follicular pattern evenly such as on the face and neck; grade II, with complete depletion of epidermal melanocytes with a usual follicular pattern of repigmentation; and grade III, indicating complete depletion of follicular melanocytes with no hope of response to medical therapy. According to Rusfianti and Wirohadidjodjo,² the surgical techniques that have developed over the years for treatment of grade III vitiligo patients include split-thickness skin grafting, suction blister grafting, miniature punch grafting, and cultured melanocyte transplantation.

Surgical Techniques

Split-thickness skin grafting is an older procedure that entails the use of a harvesting graft site with no pigment loss and dermabrasion of the recipient area to allow interaction with the wound bed.⁹ With proper care and minimal movement or wrinkling of the graft site, patients can have repigmentation without skip areas.

Suction blister grafting is another tried and tested surgical intervention. Hasegawa et al¹⁰ conducted a study of 15 patients (13 males, 2 females; age range, 16–38 years) diagnosed with segmental vitiligo who were treated using the suction blister grafting technique with CO₂ laser resurfacing. Patients were recruited 1 month prior to initiating therapy and no other treatments were used during the month or in conjunction with the surgical intervention. Suction blisters were harvested from the left thigh and transferred in saline to the recipient site, which was abraded with 1 pass of the short-pulse CO₂ laser system. The recipient sites were then closed with 7-0 nylon sutures and covered tightly with tie-over dressings for at least 1 week. Within 6 months of the procedure, a treatment response of 100% was seen in 15 patients, making it an effective method for treatment-resistant vitiligo patients.¹⁰

Miniature punch grafting is another possible treatment option for resistant cases of vitiligo. Mapar et al¹¹ conducted a study in 25 patients (21 women, 4 men; age range, 20–47 years) who had been diagnosed with stable vitiligo (ie, no progression in the last 2 years) and were treated with single hair follicle transplant versus miniature punch grafting. The theory behind the study was to use the melanocytic reservoir noted in the normal hair follicle to repigment the vitiligo patch. With follow-up of both methods of treatment, there was no statistical difference in treatment results.¹¹ A similar study was conducted by Malakar and Lahiri¹² in patients with lip leukoderma (a variant of vitiligo). One hundred eight patients (41 males, 67 females; age range, 14–62 years) who had been diagnosed with stable lip leukoderma (ie, stable vitiligo for at least 6 months) underwent treatment via autologous miniature punch grafting. Punch biopsies were performed in donor sites of the buttocks and upper thighs with 72% of patients noting complete repigmentation. Complications noted were herpes labialis–induced lip leukoderma, which ultimately led to rejection of the graft site.¹² Overall, however, miniature punch grafting is a viable surgical option in stable vitiligo patients.

Cultured melanocyte transplantation, or a noncultured epidermal suspension, was first initiated in 1992.¹³ Silpa-Archa et al¹⁴ conducted an open, split-comparison study of 6 vitiligo patients (5 women, 1 man; age range, 20–65 years) with stable lesions. Fifty percent of patients received autologous pigmented skin cellular suspension, which was applied to vitiligo-affected skin that was treated with a fractionated CO₂ laser, and 50% received dermabrasion. Composite dressing was placed overlying the site with dressing removal in 1 week. The degree of repigmentation was based on a modified vitiligo area scoring index scale of poor (0%–25%), fair (26%–50%), good (51%–75%), very good (76%–90%), or excellent (91%–100%). Overall repigmentation was very good to excellent in all 6 patients.¹⁴ Potentially, this method can far improve the surgical treatment options for future vitiligo patients.

Final Thoughts

Overall, when evaluating surgical interventions for the treatment of vitiligo, careful consideration of the patient’s disease progression, failed therapies, outcome expectations, and repigmentation is warranted prior to initiating any procedure. For appropriate candidates, a range of surgical methodologies has proven to be effective in treatment of stable vitiligo patients.

Vitiligo is a common, asymptomatic, acquired depigmentation disorder that is caused by an unknown etiology. Lesions appear as sharply demarcated, depigmented macules and patches that are scattered symmetrically or unsymmetrically over the body. The presentation can be delineated based on the segmental or nonsegmental nature of the disease. According to the revised classification/nomenclature of vitiligo,¹ the disorder can be classified as nonsegmental, segmental, mixed, or unclassified. The pathogenesis of the vitiligo disease process is due to multiple modalities that contribute to melanocyte loss. Theories for melanocyte destruction include but are not limited to autoimmunity, biochemicals, epidermal cytokines, increased hydrogen peroxide and free radicals, and humoral and cellular immune alteration.^2,3

Despite its long history, the most frustrating aspect of the vitiligo disease process remains its treatment due to limited efficacy, frequent application of topicals, and the need for high-potency steroids. Medical therapies usually are the first line of treatment and are most effective with few side effects for bilateral nonsegmental or evolving vitiligo.² Some of the primary therapies with the highest efficacies appear to be calcipotriene and psoralen plus UVA, psoralen plus UVA as monotherapy, excimer laser, narrowband UVB, oral steroids, 8-methoxypsoralen, tacrolimus, and topical steroids.⁴ The theory is that these treatments would be successful if the patient had active melanocytes in the external root sheath that would be able to repigment a patch of vitiligo.⁵ Hence, it would be more difficult to treat areas such as the dorsal aspect of the fingers and toes because they lack hair-bearing areas with melanocytes.⁶ The alternative approach to treating vitiligo patches would be surgical intervention techniques, as they provide melanocytic cells to a previously depigmented area.^3,5 The focus of this article is to evaluate the efficacy and appropriate use of some of the surgical procedures that can be used in the treatment of vitiligo patients.

Candidate Selection

First, vitiligo patients for whom first-line treatment with medical therapies has failed are candidates for surgical techniques. The second vital component is to clinically confirm the diagnosis of vitiligo as opposed to other genetic, infectious, or autoimmune causes of pigment loss. Lastly, the vitiligo patch should be stable. A stable vitiligo patch does not continue to progress and is no longer responsive to topical medications that are meant to repigment for a discernible period of time.⁷

Classification of Disease Stage

To classify the stage of vitiligo prior to surgical intervention, Gauthier⁸ created a basic grading system: grade I, with partial depletion of epidermal melanocytes in a vitiligo patch that responds to repigmentation in a follicular pattern evenly such as on the face and neck; grade II, with complete depletion of epidermal melanocytes with a usual follicular pattern of repigmentation; and grade III, indicating complete depletion of follicular melanocytes with no hope of response to medical therapy. According to Rusfianti and Wirohadidjodjo,² the surgical techniques that have developed over the years for treatment of grade III vitiligo patients include split-thickness skin grafting, suction blister grafting, miniature punch grafting, and cultured melanocyte transplantation.

Surgical Techniques

Split-thickness skin grafting is an older procedure that entails the use of a harvesting graft site with no pigment loss and dermabrasion of the recipient area to allow interaction with the wound bed.⁹ With proper care and minimal movement or wrinkling of the graft site, patients can have repigmentation without skip areas.

Suction blister grafting is another tried and tested surgical intervention. Hasegawa et al¹⁰ conducted a study of 15 patients (13 males, 2 females; age range, 16–38 years) diagnosed with segmental vitiligo who were treated using the suction blister grafting technique with CO₂ laser resurfacing. Patients were recruited 1 month prior to initiating therapy and no other treatments were used during the month or in conjunction with the surgical intervention. Suction blisters were harvested from the left thigh and transferred in saline to the recipient site, which was abraded with 1 pass of the short-pulse CO₂ laser system. The recipient sites were then closed with 7-0 nylon sutures and covered tightly with tie-over dressings for at least 1 week. Within 6 months of the procedure, a treatment response of 100% was seen in 15 patients, making it an effective method for treatment-resistant vitiligo patients.¹⁰

Miniature punch grafting is another possible treatment option for resistant cases of vitiligo. Mapar et al¹¹ conducted a study in 25 patients (21 women, 4 men; age range, 20–47 years) who had been diagnosed with stable vitiligo (ie, no progression in the last 2 years) and were treated with single hair follicle transplant versus miniature punch grafting. The theory behind the study was to use the melanocytic reservoir noted in the normal hair follicle to repigment the vitiligo patch. With follow-up of both methods of treatment, there was no statistical difference in treatment results.¹¹ A similar study was conducted by Malakar and Lahiri¹² in patients with lip leukoderma (a variant of vitiligo). One hundred eight patients (41 males, 67 females; age range, 14–62 years) who had been diagnosed with stable lip leukoderma (ie, stable vitiligo for at least 6 months) underwent treatment via autologous miniature punch grafting. Punch biopsies were performed in donor sites of the buttocks and upper thighs with 72% of patients noting complete repigmentation. Complications noted were herpes labialis–induced lip leukoderma, which ultimately led to rejection of the graft site.¹² Overall, however, miniature punch grafting is a viable surgical option in stable vitiligo patients.

Cultured melanocyte transplantation, or a noncultured epidermal suspension, was first initiated in 1992.¹³ Silpa-Archa et al¹⁴ conducted an open, split-comparison study of 6 vitiligo patients (5 women, 1 man; age range, 20–65 years) with stable lesions. Fifty percent of patients received autologous pigmented skin cellular suspension, which was applied to vitiligo-affected skin that was treated with a fractionated CO₂ laser, and 50% received dermabrasion. Composite dressing was placed overlying the site with dressing removal in 1 week. The degree of repigmentation was based on a modified vitiligo area scoring index scale of poor (0%–25%), fair (26%–50%), good (51%–75%), very good (76%–90%), or excellent (91%–100%). Overall repigmentation was very good to excellent in all 6 patients.¹⁴ Potentially, this method can far improve the surgical treatment options for future vitiligo patients.

Final Thoughts

Overall, when evaluating surgical interventions for the treatment of vitiligo, careful consideration of the patient’s disease progression, failed therapies, outcome expectations, and repigmentation is warranted prior to initiating any procedure. For appropriate candidates, a range of surgical methodologies has proven to be effective in treatment of stable vitiligo patients.

Vitiligo is a common, asymptomatic, acquired depigmentation disorder that is caused by an unknown etiology. Lesions appear as sharply demarcated, depigmented macules and patches that are scattered symmetrically or unsymmetrically over the body. The presentation can be delineated based on the segmental or nonsegmental nature of the disease. According to the revised classification/nomenclature of vitiligo,¹ the disorder can be classified as nonsegmental, segmental, mixed, or unclassified. The pathogenesis of the vitiligo disease process is due to multiple modalities that contribute to melanocyte loss. Theories for melanocyte destruction include but are not limited to autoimmunity, biochemicals, epidermal cytokines, increased hydrogen peroxide and free radicals, and humoral and cellular immune alteration.^2,3

Despite its long history, the most frustrating aspect of the vitiligo disease process remains its treatment due to limited efficacy, frequent application of topicals, and the need for high-potency steroids. Medical therapies usually are the first line of treatment and are most effective with few side effects for bilateral nonsegmental or evolving vitiligo.² Some of the primary therapies with the highest efficacies appear to be calcipotriene and psoralen plus UVA, psoralen plus UVA as monotherapy, excimer laser, narrowband UVB, oral steroids, 8-methoxypsoralen, tacrolimus, and topical steroids.⁴ The theory is that these treatments would be successful if the patient had active melanocytes in the external root sheath that would be able to repigment a patch of vitiligo.⁵ Hence, it would be more difficult to treat areas such as the dorsal aspect of the fingers and toes because they lack hair-bearing areas with melanocytes.⁶ The alternative approach to treating vitiligo patches would be surgical intervention techniques, as they provide melanocytic cells to a previously depigmented area.^3,5 The focus of this article is to evaluate the efficacy and appropriate use of some of the surgical procedures that can be used in the treatment of vitiligo patients.

Candidate Selection

First, vitiligo patients for whom first-line treatment with medical therapies has failed are candidates for surgical techniques. The second vital component is to clinically confirm the diagnosis of vitiligo as opposed to other genetic, infectious, or autoimmune causes of pigment loss. Lastly, the vitiligo patch should be stable. A stable vitiligo patch does not continue to progress and is no longer responsive to topical medications that are meant to repigment for a discernible period of time.⁷

Classification of Disease Stage

To classify the stage of vitiligo prior to surgical intervention, Gauthier⁸ created a basic grading system: grade I, with partial depletion of epidermal melanocytes in a vitiligo patch that responds to repigmentation in a follicular pattern evenly such as on the face and neck; grade II, with complete depletion of epidermal melanocytes with a usual follicular pattern of repigmentation; and grade III, indicating complete depletion of follicular melanocytes with no hope of response to medical therapy. According to Rusfianti and Wirohadidjodjo,² the surgical techniques that have developed over the years for treatment of grade III vitiligo patients include split-thickness skin grafting, suction blister grafting, miniature punch grafting, and cultured melanocyte transplantation.

Surgical Techniques

Split-thickness skin grafting is an older procedure that entails the use of a harvesting graft site with no pigment loss and dermabrasion of the recipient area to allow interaction with the wound bed.⁹ With proper care and minimal movement or wrinkling of the graft site, patients can have repigmentation without skip areas.

Suction blister grafting is another tried and tested surgical intervention. Hasegawa et al¹⁰ conducted a study of 15 patients (13 males, 2 females; age range, 16–38 years) diagnosed with segmental vitiligo who were treated using the suction blister grafting technique with CO₂ laser resurfacing. Patients were recruited 1 month prior to initiating therapy and no other treatments were used during the month or in conjunction with the surgical intervention. Suction blisters were harvested from the left thigh and transferred in saline to the recipient site, which was abraded with 1 pass of the short-pulse CO₂ laser system. The recipient sites were then closed with 7-0 nylon sutures and covered tightly with tie-over dressings for at least 1 week. Within 6 months of the procedure, a treatment response of 100% was seen in 15 patients, making it an effective method for treatment-resistant vitiligo patients.¹⁰

Miniature punch grafting is another possible treatment option for resistant cases of vitiligo. Mapar et al¹¹ conducted a study in 25 patients (21 women, 4 men; age range, 20–47 years) who had been diagnosed with stable vitiligo (ie, no progression in the last 2 years) and were treated with single hair follicle transplant versus miniature punch grafting. The theory behind the study was to use the melanocytic reservoir noted in the normal hair follicle to repigment the vitiligo patch. With follow-up of both methods of treatment, there was no statistical difference in treatment results.¹¹ A similar study was conducted by Malakar and Lahiri¹² in patients with lip leukoderma (a variant of vitiligo). One hundred eight patients (41 males, 67 females; age range, 14–62 years) who had been diagnosed with stable lip leukoderma (ie, stable vitiligo for at least 6 months) underwent treatment via autologous miniature punch grafting. Punch biopsies were performed in donor sites of the buttocks and upper thighs with 72% of patients noting complete repigmentation. Complications noted were herpes labialis–induced lip leukoderma, which ultimately led to rejection of the graft site.¹² Overall, however, miniature punch grafting is a viable surgical option in stable vitiligo patients.

Cultured melanocyte transplantation, or a noncultured epidermal suspension, was first initiated in 1992.¹³ Silpa-Archa et al¹⁴ conducted an open, split-comparison study of 6 vitiligo patients (5 women, 1 man; age range, 20–65 years) with stable lesions. Fifty percent of patients received autologous pigmented skin cellular suspension, which was applied to vitiligo-affected skin that was treated with a fractionated CO₂ laser, and 50% received dermabrasion. Composite dressing was placed overlying the site with dressing removal in 1 week. The degree of repigmentation was based on a modified vitiligo area scoring index scale of poor (0%–25%), fair (26%–50%), good (51%–75%), very good (76%–90%), or excellent (91%–100%). Overall repigmentation was very good to excellent in all 6 patients.¹⁴ Potentially, this method can far improve the surgical treatment options for future vitiligo patients.

Final Thoughts

Overall, when evaluating surgical interventions for the treatment of vitiligo, careful consideration of the patient’s disease progression, failed therapies, outcome expectations, and repigmentation is warranted prior to initiating any procedure. For appropriate candidates, a range of surgical methodologies has proven to be effective in treatment of stable vitiligo patients.