For Residents

The percentage of dermatology residents pursuing fellowship training is steadily increasing. A report from the American Board of Dermatology described an increase in the percentage of residents entering fellowships approved by the American Board of Dermatology and Accreditation Council for Graduate Medical Education from 10% in 2006 to 24% in 2010.¹ The American Medical Association Residency & Fellowship Database FREIDA Online showed that 30% of dermatology residents or fellows pursued further fellowship training in 2013.² The number of dermatology fellowship positions offered also is steadily increasing. Data from SF Match showed that the number of participating applicants in Mohs micrographic surgery (MMS) fellowships increased from 64 in 2002 to 86 in 2014, and the number of programs increased from 48 to 56, respectively.³ Similarly, in pediatric dermatology the SF Match reported an increase from 14 to 22 in participating applicants and an increase in available programs from 14 to 20 in 2009 and 2012, respectively.4 Reports on dermatopathology programs also have suggested either a stable or increased percentage of residents pursuing fellowships in this specialty.^5,6

There are several reported factors that influence the pursuit of dermatology fellowships. Fellows often hope to gain further exposure to a dermatology subspecialty,⁷ which is especially applicable to procedural dermatology, as the prevailing opinion among dermatologists is that residency training should emphasize medical dermatology much more than surgery.^8,9 Increased financial compensation, responsibility to provide for a family, and increased levels of educational debt do not notably influence the desire to pursue a fellowship, though these factors often play a role in the decision to pursue a career in academia.^6,10-12 Additionally, it has been reported that fellowship-trained dermatologists are more likely to teach students, residents, and fellows and are up to 8 times more likely to participate in research than non–fellowship-trained dermatologists.^6,8,11 Research activity also correlates with the decision to pursue an academic career. As such, fellowship training may present physicians with opportunities to improve clinical care, garner more research opportunities, and advance in academic rank.¹³

Scholarly productivity, measured by contribution to research, is a heavily weighted factor when hiring and promoting within academic medicine.^14-17 Despite the importance of scholarly productivity, it is difficult to accurately quantify the measure. Commonly used metrics include number of publications, number of citations, amount of National Institutes of Health funding, number of research presentations, and number of lectures.^18,19 However, taken individually, none of these measures entirely represents an individual’s research contribution. For example, a physician may have a large number of relatively low-quality publications. Additionally, if considering the number of citations, one of an author’s publications may have many citations, while the remaining publications do not.

The h-index, introduced in 2005 by Hirsch,^20,21 is a measure of academic productivity that takes into account both the quantity and impact of research measured by recording the number of published articles and the number of citations in peer-reviewed journals. A high h-index indicates a high number of significant publications. For example, if a physician has 10 published articles cited 10 times each, his/her h-index is 10. Another physician with an h-index of 10 may have published 50 articles, which indicates that the remaining 40 articles were cited fewer than 10 times. Prior studies on the use of the h-index in fields as diverse as otolaryngology, radiology, anesthesiology, neurosurgery, ophthalmology, and urology indicate a strong association between the h-index and academic rank.^22-28 Other studies indicate that fellowship-trained individuals tend to have a higher h-index than their non–fellowship-trained counterparts.^29,30 One study demonstrated that fellowship-trained dermatologic surgeons had significantly increased academic productivity (P=.001), as measured by the number of publications in PubMed, compared to non–fellowship-trained dermatologic surgeons.¹¹

The goal of this study was to determine whether dermatology fellowship training impacts scholarly productivity and academic promotion. Additionally, the scholarly productivity of procedural dermatology/MMS, dermatopathology, and pediatric dermatology fellows is compared to determine if type of subspecialty affects research productivity.

Methods

A list of academic dermatology departments was accessed using FREIDA Online. Individual departmental websites were visited to compile a list of academic faculty members. Additional recorded data included academic rank, gender, and fellowship training. Academic rank was classified as assistant professor, associate professor, professor, and chair. Physicians listed as chairs were not listed as professors to avoid duplication of these individuals. Voluntary, nonclinical, and nonacademic faculty members were excluded from the analysis. Departments that did not list the academic rank of faculty members also were excluded. Faculty members were organized by fellowship type: procedural dermatology/MMS, dermatopathology, pediatric dermatology, other fellowship, and no fellowship. Individuals with multiple fellowships were counted in multiple categories.

Faculty members were subsequently searched on the Scopus database to determine the h-index and publication range in years. Correct author identity was ensured by confirming correct departmental affiliations and publications related to dermatology. (Results collected from the Scopus database have been shown to correlate well with those ofISI Web of Knowledge.²³)

Kruskal-Wallis tests were used to compare continuous variables, and the Pearson χ² test was used to compare categorical variables. Statistical significance was set at P<.05. All statistical analyses were performed using SAS software. This study qualified as nonhuman subject research per the institutional review board of Rutgers New Jersey Medical School (Newark, New Jersey).

Results

The analysis included 1043 faculty members from 103 academic departments. There were 144 dermatologists (13.8%) with procedural dermatology/MMS fellowships, 162 (15.5%) with dermatopathology fellowships, 71 (6.8%) with pediatric dermatology fellowships, 124 (11.9%) with other fellowships, and 542 (52.0%) with no fellowships (Figure 1). Fellowships classified as other included immunodermatology, dermatology-rheumatology, clinical education, dermatoepidemiology, cutaneous oncology, dermatopharmacology, and photobiology. Fellowship-trained dermatologists had a higher mean h-index than dermatologists without fellowships (13.2 vs 11.7; P<.001)(Figure 2).

There were significant statistical differences among the fellowships examined (Kruskal-Wallis analysis of variance, P<.05). Academic dermatologists who completed dermatopathology or other fellowships had higher scholarly productivity than those who completed pediatric dermatology and procedural dermatology/MMS fellowships (P<.05)(Figure 3). Those who did not complete a fellowship had a higher mean h-index than those who completed pediatric dermatology and procedural dermatology/MMS fellowships; however, the difference was not statistically significant.

Regarding academic rank, there was a significant increase in scholarly productivity (as measured by the h-index) from assistant professor to professor (P<.05). There was no statistical difference in scholarly productivity between professors and chairs. When controlling for academic rank, there were no statistically significant differences in h-index between fellowship-trained versus non–fellowship-trained dermatologists, except at the level of associate professor. However, fellowship-trained dermatologists consistently had a higher mean h-index compared to non–fellowship-trained dermatologists in each rank (Figure 4). Fellowship-trained dermatologists made up 48.2% (222/461) of assistant professors, 45.2% (103/228) of associate professors, 47.3% (125/264) of professors, and 56.7% (51/90) of chairs.

When controlling for the number of active publication years, no statistically significant differences were found between scholarly productivity in fellowship-trained versus non–fellowship-trained dermatologists. However, fellowship-trained academic dermatologists consistently had a higher mean h-index than non–fellowship-trained dermatologists within each 10-year range, except for the 31- to 40-year range (Figure 5).

Comment

The proportion of dermatology residents who pursue fellowship training has been steadily increasing, according to data from the American Medical Association and American Board of Dermatology.^1,2 Fellowship training allows graduating residents to have greater exposure to a dermatology subspecialty and often provides a narrower focus for future clinical activities. In our study, we found that fellowship-trained dermatologists had significantly higher research productivity, as measured by the h-index, than academic dermatologists without fellowship, which is likely because fellowship training offers an opportunity to hone teaching skills and pursue more research activity.¹³ For instance, several fellowship programs allow focused research time during training.¹¹ Additionally, residents pursuing fellowships may be more likely to engage in research activities.

Greater scholarly productivity is especially important for academic physicians, as it plays an important role in hiring and promoting.^14,15,19,31 Additionally, increased research productivity has been found to be associated with improved teaching and clinical activity.¹⁹ Research productivity of faculty members also influences the reputation and prestige of the department and the institution’s subsequent ability to attract higher-quality residents and faculty members.²⁸

There were significant differences in mean h-index between dermatology subspecialties. Academic dermatologists who completed procedural dermatology/MMS fellowships had the lowest mean h-index, while those who completed dermatopathology or other fellowships had the highest mean h-index. These findings suggest that an emphasis on research productivity may be greater in dermatopathology. Additionally, dermatologists who completed other fellowships, such as immunodermatology or dermatopharmacology, may have received such fellowships prior to dermatology training. It would be interesting to determine the amount of time allocated for research within each subspecialty fellowship training.

A greater amount of clinical responsibility also may influence the difference in measures of scholarly productivity within each subspecialty. For instance, there is a known shortage of pediatric dermatologists,³² which may translate as a decreased amount of time that can be dedicated to research activity because of higher clinical volume per physician. Dermatologists with no fellowship had a higher mean h-index than those with pediatric and procedural dermatology/MMS fellowships, which may reflect the smaller number of subspecialists compared to non–fellowship-trained dermatologists (13.8% procedural dermatology/MMS; 6.8% pediatric dermatology; 52.0% no fellowship). As such, the research of subspecialists is targeted to a narrower audience and will garner fewer citations than non–fellowship-trained dermatologists. However, the lower number of subspecialists is not the only factor impacting scholarly productivity, as dermato-pathologists had higher scholarly impact than non–fellowship-trained individuals despite comprising only 15.5% of the cohort.

In corroboration with prior studies of academic medicine, the h-index increased with increasing rank from assistant professor to professor and chair.^29,30,33 This increase confirms that research productivity is associated with academic rank. When stratifying the 2 cohorts of fellowship-trained and non–fellowship-trained academic dermatologists by academic rank, there was no significant difference in the h-index for both groups at each rank, except for associate professor. In addition, there was a relatively equal distribution within each rank of fellowship-trained and non–fellowship-trained individuals. This lack of statistical difference also was demonstrated when stratifying for years of active publication experience. Academic dermatologists have been shown to be more interested in pursuing research activity, and research is pivotal to pursuing a dermatology residency.¹¹ Future studies may extend the comparison of scholarly productivity to nonacademic dermatologists.

It is important to acknowledge certain limitations in the data collection process and use of the h-index. Many of the dermatology department websites do not provide information about whether individual faculty members are pursuing a tenure track or nontenure track. This distinction may have bearing on the h-index, as research is more heavily emphasized in the tenure track. Moreover, the h-index does not take into account the type of research (ie, clinical vs basic science research). Therefore, while basic science research often is more time intensive than clinical research, a publication is weighed solely by its number of citations. As such, the h-index may not capture the true amount of time dedicated to research activities. In addition, the h-index cannot account for self-citation, which may increase this measure.³⁴ However, to greatly influence the h-index, many self-citations of each work would be necessary, making it less concerning. Another limitation of this study is that it does not take into account time dedicated to the education of residents and medical students, an act that is necessary for preservation of the field. Although education portfolios that detail an individual’s contribution to teaching are starting to become more popular, there currently is no measure for educational activities.^18,35 Finally, dermatology department websites are not frequently updated; as such, data gathered from websites regarding academic rank may not always be recent.

Conclusion

Scholarly productivity, as measured by the h-index, is a major contributory factor to hiring, promoting, and developing reputations in academic medicine. Our findings demonstrate that there is greater scholarly productivity among fellowship-trained dermatologists compared to non–fellowship-trained dermatologists. However, when controlling for academic rank and publication range, this difference is minimized. As such, fellowships may provide more opportunity for structured research experiences but may not be necessary for successful academic careers. In addition, individuals who wish to dedicate a substantial portion of time to research may find that fellowships in dermatopathology, immunodermatology, dermatology-rheumatology, clinical education, dermatoepidemiology, cutaneous oncology, dermatopharmacology, and photobiology are more conducive to performing research. We also recommend that other activities, including clinical and teaching activities, serve as supplemental measures to scholarly productivity when evaluating a physician’s contribution.

The percentage of dermatology residents pursuing fellowship training is steadily increasing. A report from the American Board of Dermatology described an increase in the percentage of residents entering fellowships approved by the American Board of Dermatology and Accreditation Council for Graduate Medical Education from 10% in 2006 to 24% in 2010.¹ The American Medical Association Residency & Fellowship Database FREIDA Online showed that 30% of dermatology residents or fellows pursued further fellowship training in 2013.² The number of dermatology fellowship positions offered also is steadily increasing. Data from SF Match showed that the number of participating applicants in Mohs micrographic surgery (MMS) fellowships increased from 64 in 2002 to 86 in 2014, and the number of programs increased from 48 to 56, respectively.³ Similarly, in pediatric dermatology the SF Match reported an increase from 14 to 22 in participating applicants and an increase in available programs from 14 to 20 in 2009 and 2012, respectively.4 Reports on dermatopathology programs also have suggested either a stable or increased percentage of residents pursuing fellowships in this specialty.^5,6

There are several reported factors that influence the pursuit of dermatology fellowships. Fellows often hope to gain further exposure to a dermatology subspecialty,⁷ which is especially applicable to procedural dermatology, as the prevailing opinion among dermatologists is that residency training should emphasize medical dermatology much more than surgery.^8,9 Increased financial compensation, responsibility to provide for a family, and increased levels of educational debt do not notably influence the desire to pursue a fellowship, though these factors often play a role in the decision to pursue a career in academia.^6,10-12 Additionally, it has been reported that fellowship-trained dermatologists are more likely to teach students, residents, and fellows and are up to 8 times more likely to participate in research than non–fellowship-trained dermatologists.^6,8,11 Research activity also correlates with the decision to pursue an academic career. As such, fellowship training may present physicians with opportunities to improve clinical care, garner more research opportunities, and advance in academic rank.¹³

Scholarly productivity, measured by contribution to research, is a heavily weighted factor when hiring and promoting within academic medicine.^14-17 Despite the importance of scholarly productivity, it is difficult to accurately quantify the measure. Commonly used metrics include number of publications, number of citations, amount of National Institutes of Health funding, number of research presentations, and number of lectures.^18,19 However, taken individually, none of these measures entirely represents an individual’s research contribution. For example, a physician may have a large number of relatively low-quality publications. Additionally, if considering the number of citations, one of an author’s publications may have many citations, while the remaining publications do not.

The h-index, introduced in 2005 by Hirsch,^20,21 is a measure of academic productivity that takes into account both the quantity and impact of research measured by recording the number of published articles and the number of citations in peer-reviewed journals. A high h-index indicates a high number of significant publications. For example, if a physician has 10 published articles cited 10 times each, his/her h-index is 10. Another physician with an h-index of 10 may have published 50 articles, which indicates that the remaining 40 articles were cited fewer than 10 times. Prior studies on the use of the h-index in fields as diverse as otolaryngology, radiology, anesthesiology, neurosurgery, ophthalmology, and urology indicate a strong association between the h-index and academic rank.^22-28 Other studies indicate that fellowship-trained individuals tend to have a higher h-index than their non–fellowship-trained counterparts.^29,30 One study demonstrated that fellowship-trained dermatologic surgeons had significantly increased academic productivity (P=.001), as measured by the number of publications in PubMed, compared to non–fellowship-trained dermatologic surgeons.¹¹

The goal of this study was to determine whether dermatology fellowship training impacts scholarly productivity and academic promotion. Additionally, the scholarly productivity of procedural dermatology/MMS, dermatopathology, and pediatric dermatology fellows is compared to determine if type of subspecialty affects research productivity.

Methods

A list of academic dermatology departments was accessed using FREIDA Online. Individual departmental websites were visited to compile a list of academic faculty members. Additional recorded data included academic rank, gender, and fellowship training. Academic rank was classified as assistant professor, associate professor, professor, and chair. Physicians listed as chairs were not listed as professors to avoid duplication of these individuals. Voluntary, nonclinical, and nonacademic faculty members were excluded from the analysis. Departments that did not list the academic rank of faculty members also were excluded. Faculty members were organized by fellowship type: procedural dermatology/MMS, dermatopathology, pediatric dermatology, other fellowship, and no fellowship. Individuals with multiple fellowships were counted in multiple categories.

Faculty members were subsequently searched on the Scopus database to determine the h-index and publication range in years. Correct author identity was ensured by confirming correct departmental affiliations and publications related to dermatology. (Results collected from the Scopus database have been shown to correlate well with those ofISI Web of Knowledge.²³)

Kruskal-Wallis tests were used to compare continuous variables, and the Pearson χ² test was used to compare categorical variables. Statistical significance was set at P<.05. All statistical analyses were performed using SAS software. This study qualified as nonhuman subject research per the institutional review board of Rutgers New Jersey Medical School (Newark, New Jersey).

Results

The analysis included 1043 faculty members from 103 academic departments. There were 144 dermatologists (13.8%) with procedural dermatology/MMS fellowships, 162 (15.5%) with dermatopathology fellowships, 71 (6.8%) with pediatric dermatology fellowships, 124 (11.9%) with other fellowships, and 542 (52.0%) with no fellowships (Figure 1). Fellowships classified as other included immunodermatology, dermatology-rheumatology, clinical education, dermatoepidemiology, cutaneous oncology, dermatopharmacology, and photobiology. Fellowship-trained dermatologists had a higher mean h-index than dermatologists without fellowships (13.2 vs 11.7; P<.001)(Figure 2).

There were significant statistical differences among the fellowships examined (Kruskal-Wallis analysis of variance, P<.05). Academic dermatologists who completed dermatopathology or other fellowships had higher scholarly productivity than those who completed pediatric dermatology and procedural dermatology/MMS fellowships (P<.05)(Figure 3). Those who did not complete a fellowship had a higher mean h-index than those who completed pediatric dermatology and procedural dermatology/MMS fellowships; however, the difference was not statistically significant.

Regarding academic rank, there was a significant increase in scholarly productivity (as measured by the h-index) from assistant professor to professor (P<.05). There was no statistical difference in scholarly productivity between professors and chairs. When controlling for academic rank, there were no statistically significant differences in h-index between fellowship-trained versus non–fellowship-trained dermatologists, except at the level of associate professor. However, fellowship-trained dermatologists consistently had a higher mean h-index compared to non–fellowship-trained dermatologists in each rank (Figure 4). Fellowship-trained dermatologists made up 48.2% (222/461) of assistant professors, 45.2% (103/228) of associate professors, 47.3% (125/264) of professors, and 56.7% (51/90) of chairs.

When controlling for the number of active publication years, no statistically significant differences were found between scholarly productivity in fellowship-trained versus non–fellowship-trained dermatologists. However, fellowship-trained academic dermatologists consistently had a higher mean h-index than non–fellowship-trained dermatologists within each 10-year range, except for the 31- to 40-year range (Figure 5).

Comment

The proportion of dermatology residents who pursue fellowship training has been steadily increasing, according to data from the American Medical Association and American Board of Dermatology.^1,2 Fellowship training allows graduating residents to have greater exposure to a dermatology subspecialty and often provides a narrower focus for future clinical activities. In our study, we found that fellowship-trained dermatologists had significantly higher research productivity, as measured by the h-index, than academic dermatologists without fellowship, which is likely because fellowship training offers an opportunity to hone teaching skills and pursue more research activity.¹³ For instance, several fellowship programs allow focused research time during training.¹¹ Additionally, residents pursuing fellowships may be more likely to engage in research activities.

Greater scholarly productivity is especially important for academic physicians, as it plays an important role in hiring and promoting.^14,15,19,31 Additionally, increased research productivity has been found to be associated with improved teaching and clinical activity.¹⁹ Research productivity of faculty members also influences the reputation and prestige of the department and the institution’s subsequent ability to attract higher-quality residents and faculty members.²⁸

There were significant differences in mean h-index between dermatology subspecialties. Academic dermatologists who completed procedural dermatology/MMS fellowships had the lowest mean h-index, while those who completed dermatopathology or other fellowships had the highest mean h-index. These findings suggest that an emphasis on research productivity may be greater in dermatopathology. Additionally, dermatologists who completed other fellowships, such as immunodermatology or dermatopharmacology, may have received such fellowships prior to dermatology training. It would be interesting to determine the amount of time allocated for research within each subspecialty fellowship training.

A greater amount of clinical responsibility also may influence the difference in measures of scholarly productivity within each subspecialty. For instance, there is a known shortage of pediatric dermatologists,³² which may translate as a decreased amount of time that can be dedicated to research activity because of higher clinical volume per physician. Dermatologists with no fellowship had a higher mean h-index than those with pediatric and procedural dermatology/MMS fellowships, which may reflect the smaller number of subspecialists compared to non–fellowship-trained dermatologists (13.8% procedural dermatology/MMS; 6.8% pediatric dermatology; 52.0% no fellowship). As such, the research of subspecialists is targeted to a narrower audience and will garner fewer citations than non–fellowship-trained dermatologists. However, the lower number of subspecialists is not the only factor impacting scholarly productivity, as dermato-pathologists had higher scholarly impact than non–fellowship-trained individuals despite comprising only 15.5% of the cohort.

In corroboration with prior studies of academic medicine, the h-index increased with increasing rank from assistant professor to professor and chair.^29,30,33 This increase confirms that research productivity is associated with academic rank. When stratifying the 2 cohorts of fellowship-trained and non–fellowship-trained academic dermatologists by academic rank, there was no significant difference in the h-index for both groups at each rank, except for associate professor. In addition, there was a relatively equal distribution within each rank of fellowship-trained and non–fellowship-trained individuals. This lack of statistical difference also was demonstrated when stratifying for years of active publication experience. Academic dermatologists have been shown to be more interested in pursuing research activity, and research is pivotal to pursuing a dermatology residency.¹¹ Future studies may extend the comparison of scholarly productivity to nonacademic dermatologists.

It is important to acknowledge certain limitations in the data collection process and use of the h-index. Many of the dermatology department websites do not provide information about whether individual faculty members are pursuing a tenure track or nontenure track. This distinction may have bearing on the h-index, as research is more heavily emphasized in the tenure track. Moreover, the h-index does not take into account the type of research (ie, clinical vs basic science research). Therefore, while basic science research often is more time intensive than clinical research, a publication is weighed solely by its number of citations. As such, the h-index may not capture the true amount of time dedicated to research activities. In addition, the h-index cannot account for self-citation, which may increase this measure.³⁴ However, to greatly influence the h-index, many self-citations of each work would be necessary, making it less concerning. Another limitation of this study is that it does not take into account time dedicated to the education of residents and medical students, an act that is necessary for preservation of the field. Although education portfolios that detail an individual’s contribution to teaching are starting to become more popular, there currently is no measure for educational activities.^18,35 Finally, dermatology department websites are not frequently updated; as such, data gathered from websites regarding academic rank may not always be recent.

Conclusion

Scholarly productivity, as measured by the h-index, is a major contributory factor to hiring, promoting, and developing reputations in academic medicine. Our findings demonstrate that there is greater scholarly productivity among fellowship-trained dermatologists compared to non–fellowship-trained dermatologists. However, when controlling for academic rank and publication range, this difference is minimized. As such, fellowships may provide more opportunity for structured research experiences but may not be necessary for successful academic careers. In addition, individuals who wish to dedicate a substantial portion of time to research may find that fellowships in dermatopathology, immunodermatology, dermatology-rheumatology, clinical education, dermatoepidemiology, cutaneous oncology, dermatopharmacology, and photobiology are more conducive to performing research. We also recommend that other activities, including clinical and teaching activities, serve as supplemental measures to scholarly productivity when evaluating a physician’s contribution.

The percentage of dermatology residents pursuing fellowship training is steadily increasing. A report from the American Board of Dermatology described an increase in the percentage of residents entering fellowships approved by the American Board of Dermatology and Accreditation Council for Graduate Medical Education from 10% in 2006 to 24% in 2010.¹ The American Medical Association Residency & Fellowship Database FREIDA Online showed that 30% of dermatology residents or fellows pursued further fellowship training in 2013.² The number of dermatology fellowship positions offered also is steadily increasing. Data from SF Match showed that the number of participating applicants in Mohs micrographic surgery (MMS) fellowships increased from 64 in 2002 to 86 in 2014, and the number of programs increased from 48 to 56, respectively.³ Similarly, in pediatric dermatology the SF Match reported an increase from 14 to 22 in participating applicants and an increase in available programs from 14 to 20 in 2009 and 2012, respectively.4 Reports on dermatopathology programs also have suggested either a stable or increased percentage of residents pursuing fellowships in this specialty.^5,6

There are several reported factors that influence the pursuit of dermatology fellowships. Fellows often hope to gain further exposure to a dermatology subspecialty,⁷ which is especially applicable to procedural dermatology, as the prevailing opinion among dermatologists is that residency training should emphasize medical dermatology much more than surgery.^8,9 Increased financial compensation, responsibility to provide for a family, and increased levels of educational debt do not notably influence the desire to pursue a fellowship, though these factors often play a role in the decision to pursue a career in academia.^6,10-12 Additionally, it has been reported that fellowship-trained dermatologists are more likely to teach students, residents, and fellows and are up to 8 times more likely to participate in research than non–fellowship-trained dermatologists.^6,8,11 Research activity also correlates with the decision to pursue an academic career. As such, fellowship training may present physicians with opportunities to improve clinical care, garner more research opportunities, and advance in academic rank.¹³

Scholarly productivity, measured by contribution to research, is a heavily weighted factor when hiring and promoting within academic medicine.^14-17 Despite the importance of scholarly productivity, it is difficult to accurately quantify the measure. Commonly used metrics include number of publications, number of citations, amount of National Institutes of Health funding, number of research presentations, and number of lectures.^18,19 However, taken individually, none of these measures entirely represents an individual’s research contribution. For example, a physician may have a large number of relatively low-quality publications. Additionally, if considering the number of citations, one of an author’s publications may have many citations, while the remaining publications do not.

The h-index, introduced in 2005 by Hirsch,^20,21 is a measure of academic productivity that takes into account both the quantity and impact of research measured by recording the number of published articles and the number of citations in peer-reviewed journals. A high h-index indicates a high number of significant publications. For example, if a physician has 10 published articles cited 10 times each, his/her h-index is 10. Another physician with an h-index of 10 may have published 50 articles, which indicates that the remaining 40 articles were cited fewer than 10 times. Prior studies on the use of the h-index in fields as diverse as otolaryngology, radiology, anesthesiology, neurosurgery, ophthalmology, and urology indicate a strong association between the h-index and academic rank.^22-28 Other studies indicate that fellowship-trained individuals tend to have a higher h-index than their non–fellowship-trained counterparts.^29,30 One study demonstrated that fellowship-trained dermatologic surgeons had significantly increased academic productivity (P=.001), as measured by the number of publications in PubMed, compared to non–fellowship-trained dermatologic surgeons.¹¹

The goal of this study was to determine whether dermatology fellowship training impacts scholarly productivity and academic promotion. Additionally, the scholarly productivity of procedural dermatology/MMS, dermatopathology, and pediatric dermatology fellows is compared to determine if type of subspecialty affects research productivity.

Methods

A list of academic dermatology departments was accessed using FREIDA Online. Individual departmental websites were visited to compile a list of academic faculty members. Additional recorded data included academic rank, gender, and fellowship training. Academic rank was classified as assistant professor, associate professor, professor, and chair. Physicians listed as chairs were not listed as professors to avoid duplication of these individuals. Voluntary, nonclinical, and nonacademic faculty members were excluded from the analysis. Departments that did not list the academic rank of faculty members also were excluded. Faculty members were organized by fellowship type: procedural dermatology/MMS, dermatopathology, pediatric dermatology, other fellowship, and no fellowship. Individuals with multiple fellowships were counted in multiple categories.

Faculty members were subsequently searched on the Scopus database to determine the h-index and publication range in years. Correct author identity was ensured by confirming correct departmental affiliations and publications related to dermatology. (Results collected from the Scopus database have been shown to correlate well with those ofISI Web of Knowledge.²³)

Kruskal-Wallis tests were used to compare continuous variables, and the Pearson χ² test was used to compare categorical variables. Statistical significance was set at P<.05. All statistical analyses were performed using SAS software. This study qualified as nonhuman subject research per the institutional review board of Rutgers New Jersey Medical School (Newark, New Jersey).

Results

The analysis included 1043 faculty members from 103 academic departments. There were 144 dermatologists (13.8%) with procedural dermatology/MMS fellowships, 162 (15.5%) with dermatopathology fellowships, 71 (6.8%) with pediatric dermatology fellowships, 124 (11.9%) with other fellowships, and 542 (52.0%) with no fellowships (Figure 1). Fellowships classified as other included immunodermatology, dermatology-rheumatology, clinical education, dermatoepidemiology, cutaneous oncology, dermatopharmacology, and photobiology. Fellowship-trained dermatologists had a higher mean h-index than dermatologists without fellowships (13.2 vs 11.7; P<.001)(Figure 2).

There were significant statistical differences among the fellowships examined (Kruskal-Wallis analysis of variance, P<.05). Academic dermatologists who completed dermatopathology or other fellowships had higher scholarly productivity than those who completed pediatric dermatology and procedural dermatology/MMS fellowships (P<.05)(Figure 3). Those who did not complete a fellowship had a higher mean h-index than those who completed pediatric dermatology and procedural dermatology/MMS fellowships; however, the difference was not statistically significant.

Regarding academic rank, there was a significant increase in scholarly productivity (as measured by the h-index) from assistant professor to professor (P<.05). There was no statistical difference in scholarly productivity between professors and chairs. When controlling for academic rank, there were no statistically significant differences in h-index between fellowship-trained versus non–fellowship-trained dermatologists, except at the level of associate professor. However, fellowship-trained dermatologists consistently had a higher mean h-index compared to non–fellowship-trained dermatologists in each rank (Figure 4). Fellowship-trained dermatologists made up 48.2% (222/461) of assistant professors, 45.2% (103/228) of associate professors, 47.3% (125/264) of professors, and 56.7% (51/90) of chairs.

When controlling for the number of active publication years, no statistically significant differences were found between scholarly productivity in fellowship-trained versus non–fellowship-trained dermatologists. However, fellowship-trained academic dermatologists consistently had a higher mean h-index than non–fellowship-trained dermatologists within each 10-year range, except for the 31- to 40-year range (Figure 5).

Comment

The proportion of dermatology residents who pursue fellowship training has been steadily increasing, according to data from the American Medical Association and American Board of Dermatology.^1,2 Fellowship training allows graduating residents to have greater exposure to a dermatology subspecialty and often provides a narrower focus for future clinical activities. In our study, we found that fellowship-trained dermatologists had significantly higher research productivity, as measured by the h-index, than academic dermatologists without fellowship, which is likely because fellowship training offers an opportunity to hone teaching skills and pursue more research activity.¹³ For instance, several fellowship programs allow focused research time during training.¹¹ Additionally, residents pursuing fellowships may be more likely to engage in research activities.

Greater scholarly productivity is especially important for academic physicians, as it plays an important role in hiring and promoting.^14,15,19,31 Additionally, increased research productivity has been found to be associated with improved teaching and clinical activity.¹⁹ Research productivity of faculty members also influences the reputation and prestige of the department and the institution’s subsequent ability to attract higher-quality residents and faculty members.²⁸

There were significant differences in mean h-index between dermatology subspecialties. Academic dermatologists who completed procedural dermatology/MMS fellowships had the lowest mean h-index, while those who completed dermatopathology or other fellowships had the highest mean h-index. These findings suggest that an emphasis on research productivity may be greater in dermatopathology. Additionally, dermatologists who completed other fellowships, such as immunodermatology or dermatopharmacology, may have received such fellowships prior to dermatology training. It would be interesting to determine the amount of time allocated for research within each subspecialty fellowship training.

A greater amount of clinical responsibility also may influence the difference in measures of scholarly productivity within each subspecialty. For instance, there is a known shortage of pediatric dermatologists,³² which may translate as a decreased amount of time that can be dedicated to research activity because of higher clinical volume per physician. Dermatologists with no fellowship had a higher mean h-index than those with pediatric and procedural dermatology/MMS fellowships, which may reflect the smaller number of subspecialists compared to non–fellowship-trained dermatologists (13.8% procedural dermatology/MMS; 6.8% pediatric dermatology; 52.0% no fellowship). As such, the research of subspecialists is targeted to a narrower audience and will garner fewer citations than non–fellowship-trained dermatologists. However, the lower number of subspecialists is not the only factor impacting scholarly productivity, as dermato-pathologists had higher scholarly impact than non–fellowship-trained individuals despite comprising only 15.5% of the cohort.

In corroboration with prior studies of academic medicine, the h-index increased with increasing rank from assistant professor to professor and chair.^29,30,33 This increase confirms that research productivity is associated with academic rank. When stratifying the 2 cohorts of fellowship-trained and non–fellowship-trained academic dermatologists by academic rank, there was no significant difference in the h-index for both groups at each rank, except for associate professor. In addition, there was a relatively equal distribution within each rank of fellowship-trained and non–fellowship-trained individuals. This lack of statistical difference also was demonstrated when stratifying for years of active publication experience. Academic dermatologists have been shown to be more interested in pursuing research activity, and research is pivotal to pursuing a dermatology residency.¹¹ Future studies may extend the comparison of scholarly productivity to nonacademic dermatologists.

It is important to acknowledge certain limitations in the data collection process and use of the h-index. Many of the dermatology department websites do not provide information about whether individual faculty members are pursuing a tenure track or nontenure track. This distinction may have bearing on the h-index, as research is more heavily emphasized in the tenure track. Moreover, the h-index does not take into account the type of research (ie, clinical vs basic science research). Therefore, while basic science research often is more time intensive than clinical research, a publication is weighed solely by its number of citations. As such, the h-index may not capture the true amount of time dedicated to research activities. In addition, the h-index cannot account for self-citation, which may increase this measure.³⁴ However, to greatly influence the h-index, many self-citations of each work would be necessary, making it less concerning. Another limitation of this study is that it does not take into account time dedicated to the education of residents and medical students, an act that is necessary for preservation of the field. Although education portfolios that detail an individual’s contribution to teaching are starting to become more popular, there currently is no measure for educational activities.^18,35 Finally, dermatology department websites are not frequently updated; as such, data gathered from websites regarding academic rank may not always be recent.

Conclusion

Scholarly productivity, as measured by the h-index, is a major contributory factor to hiring, promoting, and developing reputations in academic medicine. Our findings demonstrate that there is greater scholarly productivity among fellowship-trained dermatologists compared to non–fellowship-trained dermatologists. However, when controlling for academic rank and publication range, this difference is minimized. As such, fellowships may provide more opportunity for structured research experiences but may not be necessary for successful academic careers. In addition, individuals who wish to dedicate a substantial portion of time to research may find that fellowships in dermatopathology, immunodermatology, dermatology-rheumatology, clinical education, dermatoepidemiology, cutaneous oncology, dermatopharmacology, and photobiology are more conducive to performing research. We also recommend that other activities, including clinical and teaching activities, serve as supplemental measures to scholarly productivity when evaluating a physician’s contribution.

Books

There are a number of classic textbooks that serve as primary resources for dermatology training^1-4; however, there also are other options if memorizing these books seems a little daunting. The “first aid” books of dermatology are the Derm In-Review binder and Jain’s⁵ Dermatology: Illustrated Study Guide and Comprehensive Board Review. Mariwalla and Leffell’s⁶Primer in Dermatologic Surgery: A Study Companion is helpful for surgical review and is available at a discounted price for members of the American Society for Dermatologic Surgery (https://www.asds.net/store/product.aspx?id=3914&terms=primer%20in%20Dermatologic%20surgery). The American Academy of Dermatology (AAD) provides a list of additional textbooks that dermatology residents may find useful for board review.⁷

Guided Study

The AAD offers board review courses for dermatology residents (cost varies).⁷ The Florida Dermatology and Dermatopathology Board Review Course (http://dermatology.med.ufl.edu/education/florida-dermatology-and-dermatopathology-board-review-course/) is an annual review course held in Tampa (early registration fee, $800 [does not include travel costs]). The Oakstone Institute also offers its Dermatology Board Review Course, which is a self-study program that can be completed online for approximately $1195 (http://www.oakstone.com/dermatology-board-review-course). Be sure to take advantage of free didactics lectures, society meetings with board review courses, and study groups, as these resources can be just as helpful and more budget friendly.

Digital Resources

The Derm In-Review question bank (http://dermatologyinreview.com/Merz) is probably one of the most popular board review resources and is free to US dermatology residents; however, be cautious when using this resource, as a fair number of the answers to questions may actually be outdated or based on older studies. A group study session can help tease out why certain answers are erroneous and provide a forum for discussing what would be a more correct answer. Take advantage of the opportunity to provide feedback on this website, as your comments will improve this resource for future dermatology residents.

Beyond traditional dermatopathology textbooks, there also are some excellent mobile applications (apps) available. The Clearpath app is a user-friendly dermatopathology study tool that is free for download in the iTunes store (https://itunes.apple.com/us/app/clearpath/id540260769?mt=8). However, the app is only compatible with iPads. The Clearpath website also offers virtual study slide sets that are easier to access (http://dermpathlab.com/slide-study-set-program). Your institution’s glass slide sets also are useful for building pattern recognition skills and practicing for the actual board examination. The DermOID website (http://www.derm-oid.com), which is powered by the David Geffen School of Medicine at the University of California, Los Angeles, is another online dermatopathology study database with free registration for access to the site. Another fun way to test your dermatopathology skills is in the exhibition hall at the AAD annual meeting where some vendors may offer daily dermatopathology quizzes and prizes for the residents with the most correct answers. Also, it is worth reviewing the Cutis^® Fast Facts for Board Review (http://www.cutis.com/articles/fast-facts-for-board-review/), as this section offers many outstanding fact sheets that are an easy read and an efficient way to gain board knowledge. Some recent topics include fillers, paraneoplastic skin conditions, and medications in dermatology.

Many residents enjoy using the Anki flashcard app (http://ankisrs.net) for reviewing kodachromes. The AAD website also includes a Boards’ Fodder archive that is worth reviewing (https://www.aad.org/members/residents-fellows/boards-study-tools/boards-fodder/boards-fodder). New board review resources are constantly being posted on the AAD website, so definitely check this out. You may be able to access this resource through your residency program; it is also available for purchase ($425 for AAD members; $850 for nonmembers).

Journals

All the major dermatology journals are helpful in preparing for the board examination. Your resident journal club will likely review many of the most clinically relevant dermatology articles published over the course of your residency. Some other helpful journal resources that are recommended for board review include the Journal of the American Medical Association’s Clinical Challenge, which has many dermatologic cases (http://jama.jamanetwork.com/public/QuizzesAndPolls.aspx), and the New England Journal of Medicine’s Journal Watch (http://www.jwatch.org) and Image Challenge (http://www.nejm.org/image-challenge).

Practice Examinations

The American Board of Dermatology’s In-Training Examination is the most well-known practice examination among dermatology residents.⁸ A link to an additional practice examination usually is provided a few weeks prior to the examination. The Derm In-Review website also offers diagnostic practice examinations with some ability to custom select questions for your studying needs.

Conclusion

There are many board review resources out there. Find the ones that work for you, and be encouraged that your studying and hard work will pay off!

Books

There are a number of classic textbooks that serve as primary resources for dermatology training^1-4; however, there also are other options if memorizing these books seems a little daunting. The “first aid” books of dermatology are the Derm In-Review binder and Jain’s⁵ Dermatology: Illustrated Study Guide and Comprehensive Board Review. Mariwalla and Leffell’s⁶Primer in Dermatologic Surgery: A Study Companion is helpful for surgical review and is available at a discounted price for members of the American Society for Dermatologic Surgery (https://www.asds.net/store/product.aspx?id=3914&terms=primer%20in%20Dermatologic%20surgery). The American Academy of Dermatology (AAD) provides a list of additional textbooks that dermatology residents may find useful for board review.⁷

Guided Study

The AAD offers board review courses for dermatology residents (cost varies).⁷ The Florida Dermatology and Dermatopathology Board Review Course (http://dermatology.med.ufl.edu/education/florida-dermatology-and-dermatopathology-board-review-course/) is an annual review course held in Tampa (early registration fee, $800 [does not include travel costs]). The Oakstone Institute also offers its Dermatology Board Review Course, which is a self-study program that can be completed online for approximately $1195 (http://www.oakstone.com/dermatology-board-review-course). Be sure to take advantage of free didactics lectures, society meetings with board review courses, and study groups, as these resources can be just as helpful and more budget friendly.

Digital Resources

The Derm In-Review question bank (http://dermatologyinreview.com/Merz) is probably one of the most popular board review resources and is free to US dermatology residents; however, be cautious when using this resource, as a fair number of the answers to questions may actually be outdated or based on older studies. A group study session can help tease out why certain answers are erroneous and provide a forum for discussing what would be a more correct answer. Take advantage of the opportunity to provide feedback on this website, as your comments will improve this resource for future dermatology residents.

Beyond traditional dermatopathology textbooks, there also are some excellent mobile applications (apps) available. The Clearpath app is a user-friendly dermatopathology study tool that is free for download in the iTunes store (https://itunes.apple.com/us/app/clearpath/id540260769?mt=8). However, the app is only compatible with iPads. The Clearpath website also offers virtual study slide sets that are easier to access (http://dermpathlab.com/slide-study-set-program). Your institution’s glass slide sets also are useful for building pattern recognition skills and practicing for the actual board examination. The DermOID website (http://www.derm-oid.com), which is powered by the David Geffen School of Medicine at the University of California, Los Angeles, is another online dermatopathology study database with free registration for access to the site. Another fun way to test your dermatopathology skills is in the exhibition hall at the AAD annual meeting where some vendors may offer daily dermatopathology quizzes and prizes for the residents with the most correct answers. Also, it is worth reviewing the Cutis^® Fast Facts for Board Review (http://www.cutis.com/articles/fast-facts-for-board-review/), as this section offers many outstanding fact sheets that are an easy read and an efficient way to gain board knowledge. Some recent topics include fillers, paraneoplastic skin conditions, and medications in dermatology.

Many residents enjoy using the Anki flashcard app (http://ankisrs.net) for reviewing kodachromes. The AAD website also includes a Boards’ Fodder archive that is worth reviewing (https://www.aad.org/members/residents-fellows/boards-study-tools/boards-fodder/boards-fodder). New board review resources are constantly being posted on the AAD website, so definitely check this out. You may be able to access this resource through your residency program; it is also available for purchase ($425 for AAD members; $850 for nonmembers).

Journals

All the major dermatology journals are helpful in preparing for the board examination. Your resident journal club will likely review many of the most clinically relevant dermatology articles published over the course of your residency. Some other helpful journal resources that are recommended for board review include the Journal of the American Medical Association’s Clinical Challenge, which has many dermatologic cases (http://jama.jamanetwork.com/public/QuizzesAndPolls.aspx), and the New England Journal of Medicine’s Journal Watch (http://www.jwatch.org) and Image Challenge (http://www.nejm.org/image-challenge).

Practice Examinations

The American Board of Dermatology’s In-Training Examination is the most well-known practice examination among dermatology residents.⁸ A link to an additional practice examination usually is provided a few weeks prior to the examination. The Derm In-Review website also offers diagnostic practice examinations with some ability to custom select questions for your studying needs.

Conclusion

There are many board review resources out there. Find the ones that work for you, and be encouraged that your studying and hard work will pay off!

Books

There are a number of classic textbooks that serve as primary resources for dermatology training^1-4; however, there also are other options if memorizing these books seems a little daunting. The “first aid” books of dermatology are the Derm In-Review binder and Jain’s⁵ Dermatology: Illustrated Study Guide and Comprehensive Board Review. Mariwalla and Leffell’s⁶Primer in Dermatologic Surgery: A Study Companion is helpful for surgical review and is available at a discounted price for members of the American Society for Dermatologic Surgery (https://www.asds.net/store/product.aspx?id=3914&terms=primer%20in%20Dermatologic%20surgery). The American Academy of Dermatology (AAD) provides a list of additional textbooks that dermatology residents may find useful for board review.⁷

Guided Study

The AAD offers board review courses for dermatology residents (cost varies).⁷ The Florida Dermatology and Dermatopathology Board Review Course (http://dermatology.med.ufl.edu/education/florida-dermatology-and-dermatopathology-board-review-course/) is an annual review course held in Tampa (early registration fee, $800 [does not include travel costs]). The Oakstone Institute also offers its Dermatology Board Review Course, which is a self-study program that can be completed online for approximately $1195 (http://www.oakstone.com/dermatology-board-review-course). Be sure to take advantage of free didactics lectures, society meetings with board review courses, and study groups, as these resources can be just as helpful and more budget friendly.

Digital Resources

The Derm In-Review question bank (http://dermatologyinreview.com/Merz) is probably one of the most popular board review resources and is free to US dermatology residents; however, be cautious when using this resource, as a fair number of the answers to questions may actually be outdated or based on older studies. A group study session can help tease out why certain answers are erroneous and provide a forum for discussing what would be a more correct answer. Take advantage of the opportunity to provide feedback on this website, as your comments will improve this resource for future dermatology residents.

Beyond traditional dermatopathology textbooks, there also are some excellent mobile applications (apps) available. The Clearpath app is a user-friendly dermatopathology study tool that is free for download in the iTunes store (https://itunes.apple.com/us/app/clearpath/id540260769?mt=8). However, the app is only compatible with iPads. The Clearpath website also offers virtual study slide sets that are easier to access (http://dermpathlab.com/slide-study-set-program). Your institution’s glass slide sets also are useful for building pattern recognition skills and practicing for the actual board examination. The DermOID website (http://www.derm-oid.com), which is powered by the David Geffen School of Medicine at the University of California, Los Angeles, is another online dermatopathology study database with free registration for access to the site. Another fun way to test your dermatopathology skills is in the exhibition hall at the AAD annual meeting where some vendors may offer daily dermatopathology quizzes and prizes for the residents with the most correct answers. Also, it is worth reviewing the Cutis^® Fast Facts for Board Review (http://www.cutis.com/articles/fast-facts-for-board-review/), as this section offers many outstanding fact sheets that are an easy read and an efficient way to gain board knowledge. Some recent topics include fillers, paraneoplastic skin conditions, and medications in dermatology.

Many residents enjoy using the Anki flashcard app (http://ankisrs.net) for reviewing kodachromes. The AAD website also includes a Boards’ Fodder archive that is worth reviewing (https://www.aad.org/members/residents-fellows/boards-study-tools/boards-fodder/boards-fodder). New board review resources are constantly being posted on the AAD website, so definitely check this out. You may be able to access this resource through your residency program; it is also available for purchase ($425 for AAD members; $850 for nonmembers).

Journals

All the major dermatology journals are helpful in preparing for the board examination. Your resident journal club will likely review many of the most clinically relevant dermatology articles published over the course of your residency. Some other helpful journal resources that are recommended for board review include the Journal of the American Medical Association’s Clinical Challenge, which has many dermatologic cases (http://jama.jamanetwork.com/public/QuizzesAndPolls.aspx), and the New England Journal of Medicine’s Journal Watch (http://www.jwatch.org) and Image Challenge (http://www.nejm.org/image-challenge).

Practice Examinations

The American Board of Dermatology’s In-Training Examination is the most well-known practice examination among dermatology residents.⁸ A link to an additional practice examination usually is provided a few weeks prior to the examination. The Derm In-Review website also offers diagnostic practice examinations with some ability to custom select questions for your studying needs.

Conclusion

There are many board review resources out there. Find the ones that work for you, and be encouraged that your studying and hard work will pay off!

Some practitioners of medicine—including psychiatrists—might equate “psychosis” with incapacity, but that isn’t necessarily true. Even patients who, by most measures, are deemed psychotic might be capable of making wise and thoughtful decisions about their life. The case I describe in this article demonstrates that fact.

While rotating on a busy consultation service, I was asked to evaluate the capacity of a woman who had a diagnosis of schizophrenia and was being seen for worsening auditory hallucinations and progressive weight loss. She had a complicated medical course that eventually led to multiple requests to the consult team for a capacity evaluation.

The question of capacity in this patient, and in the psychiatric population generally, motivated me to review the literature, because the assumption by many on the medical teams involved in this patient’s care was that psychiatric patients do not have the capacity to participate in their own care. My goal here is to clarify the misconceptions in regard to this situation.

CASE REPORT
Schizophrenia, weight loss, back pain
Ms. V, age 67, a resident of a group home for the past 6 years, was brought to the emergency department (ED) because of weight loss and auditory hallucinations that had developed during the past few months. She had a history of paranoid schizophrenia that included several psychiatric hospitalizations but no known medical history.

The patient appeared cachectic and dehydrated. When approached, she was pleasant and reported hearing voices of the “devil.”

“They are not scary,” she confided. “They talk to me about art and literature.”

Over the past 6 months, Ms. V had lost 60 lb; she was now bedridden because of back pain. Collateral information obtained from staff members at the group home indicated that she had refused to get out of bed, and only intermittently took her medications or ate meals during the past few months. In general, however, she had been relatively stable over the course of her psychiatric illness, was adherent to psychiatric treatment, and had had no psychiatric hospitalizations in the past 3 decades.

Ominous development. Although the ED staff was convinced that Ms. V needed psychiatric admission, we (the consult team) first requested a detailed medical workup, including imaging studies. A CT scan showed multiple metastatic foci throughout her spine. She was admitted to the medical service.

Respiratory distress developed; her condition deteriorated. Numerous capacity consults were requested because she refused a medical workup or to sign do-not-resuscitate and do-not-intubate orders. Each time an evaluation was performed, Ms. V was deemed by various clinicians on the consult service to have decision-making capacity.

The patient grew unhappy with the staff’s insistence that she undergo more tests regardless of her stated wishes. The palliative care service determined that further workup would not benefit her medically: Ms. V’s condition would be grave and her prognosis poor regardless of what treatment she received.

The medical team continued to believe that, because that this patient had a mental illness and was actively hallucinating, she did not have the capacity to refuse any proposed treatments and tests.

What is capacity?
Capacity is an assessment of a person’s ability to make rational decisions. This includes the ability to understand, appreciate, and manipulate information in reaching such decisions. Determining whether a patient has the capacity to accept or refuse treatment is a medical decision that any physician can make; however, consultation−liaison psychiatrists are the experts who often are involved in this activity, particularly in patients who have a psychiatric comorbidity.

Capacity is evaluated by assessing 4 standards; that is, whether a patient can:

• communicate choice about proposed treatment
• understand her (his) medical situation
• appreciate the situation and its consequences
• manipulate information to reach a rational decision.^1-3
• manipulate information to reach a rational decision.
   

CASE REPORT continued
Although Ms. V’s health was deteriorating and her auditory hallucinations were becoming worse, she appeared insightful about her medical problems, understood her prognosis, and wanted comfort care. She understood that having multiple metastases meant a poor prognosis, and that a biopsy might yield a medical diagnosis. She stated, “If it were caught earlier and I was better able to tolerate treatment, it would make sense to know for sure, but now it doesn’t make sense. I just want to have no pain in my end.”
 

Misconceptions
In a study by Ganzini et al,^4,5 395 consultation−liaison psychiatrists, geriatricians, and geriatric psychologists responded to a survey in which they rated types of misunderstandings by clinicians who refer patients for assessment of decision-making capacity. Seventy percent reported that it is common that, when a patient has a mental illness such as schizophrenia, practitioners think that the patient lacks capacity to make medical decisions. However, results of a meta-analysis by Jeste et al,⁶ in which the magnitude of impairment of decisional capacity in patients with schizophrenia was assessed in comparison to that of normal subjects, suggest that the presence of schizophrenia does not necessarily mean the patient has impaired capacity.

Voluntary participation in research. Many patients with schizophrenia volunteer to participate in clinical trials even when they are acutely psychotic and admitted to a psychiatric hospital. Given the importance placed on participants’ voluntary informed consent as a prerequisite for ethical conduct of research, the cognitive and emotional impairments associated with schizophrenia raise questions about patients’ capacity to consent.

As is true in other areas of functional capacity, the ability of patients with schizophrenia to make competent decisions relates more to their overall cognitive functioning than to the presence or absence of specific symptoms of the disorder.⁷ Documentation of longitudinal consent-related abilities among research participants with schizophrenia in the long-term Clinical Antipsychotic Trials of Intervention Effectiveness study indicated that most participants had stable or improved consent-related abilities. Although almost 25% of participants experienced substantial worsening, only 4% fell below the study’s capacity threshold for enrollment.⁸

What I learned from Ms. V
A diagnosis of schizophrenia does not automatically render a person unable to make decisions about medical care. Even patients who have severe mental illness might have significant intact areas of reality testing. Ethically, it is important to at least consider that the chronically mentally ill can understand treatment options and express consistent choices.

Healthcare providers might tend to exclude psychiatric patients from end-of-life decisions because they (1) are worried about the emotional fragility of such patients and (2) assume that patients lack capacity to participate in making such important decisions. The case presented here is an example of a patient with a severe psychiatric diagnosis being able to participate in her care despite her mental state.

Some practitioners of medicine—including psychiatrists—might equate “psychosis” with incapacity, but that isn’t necessarily true. Even patients who, by most measures, are deemed psychotic might be capable of making wise and thoughtful decisions about their life. The case I describe in this article demonstrates that fact.

While rotating on a busy consultation service, I was asked to evaluate the capacity of a woman who had a diagnosis of schizophrenia and was being seen for worsening auditory hallucinations and progressive weight loss. She had a complicated medical course that eventually led to multiple requests to the consult team for a capacity evaluation.

The question of capacity in this patient, and in the psychiatric population generally, motivated me to review the literature, because the assumption by many on the medical teams involved in this patient’s care was that psychiatric patients do not have the capacity to participate in their own care. My goal here is to clarify the misconceptions in regard to this situation.

CASE REPORT
Schizophrenia, weight loss, back pain
Ms. V, age 67, a resident of a group home for the past 6 years, was brought to the emergency department (ED) because of weight loss and auditory hallucinations that had developed during the past few months. She had a history of paranoid schizophrenia that included several psychiatric hospitalizations but no known medical history.

The patient appeared cachectic and dehydrated. When approached, she was pleasant and reported hearing voices of the “devil.”

“They are not scary,” she confided. “They talk to me about art and literature.”

Over the past 6 months, Ms. V had lost 60 lb; she was now bedridden because of back pain. Collateral information obtained from staff members at the group home indicated that she had refused to get out of bed, and only intermittently took her medications or ate meals during the past few months. In general, however, she had been relatively stable over the course of her psychiatric illness, was adherent to psychiatric treatment, and had had no psychiatric hospitalizations in the past 3 decades.

Ominous development. Although the ED staff was convinced that Ms. V needed psychiatric admission, we (the consult team) first requested a detailed medical workup, including imaging studies. A CT scan showed multiple metastatic foci throughout her spine. She was admitted to the medical service.

Respiratory distress developed; her condition deteriorated. Numerous capacity consults were requested because she refused a medical workup or to sign do-not-resuscitate and do-not-intubate orders. Each time an evaluation was performed, Ms. V was deemed by various clinicians on the consult service to have decision-making capacity.

The patient grew unhappy with the staff’s insistence that she undergo more tests regardless of her stated wishes. The palliative care service determined that further workup would not benefit her medically: Ms. V’s condition would be grave and her prognosis poor regardless of what treatment she received.

The medical team continued to believe that, because that this patient had a mental illness and was actively hallucinating, she did not have the capacity to refuse any proposed treatments and tests.

What is capacity?
Capacity is an assessment of a person’s ability to make rational decisions. This includes the ability to understand, appreciate, and manipulate information in reaching such decisions. Determining whether a patient has the capacity to accept or refuse treatment is a medical decision that any physician can make; however, consultation−liaison psychiatrists are the experts who often are involved in this activity, particularly in patients who have a psychiatric comorbidity.

Capacity is evaluated by assessing 4 standards; that is, whether a patient can:

• communicate choice about proposed treatment
• understand her (his) medical situation
• appreciate the situation and its consequences
• manipulate information to reach a rational decision.^1-3
• manipulate information to reach a rational decision.
   

CASE REPORT continued
Although Ms. V’s health was deteriorating and her auditory hallucinations were becoming worse, she appeared insightful about her medical problems, understood her prognosis, and wanted comfort care. She understood that having multiple metastases meant a poor prognosis, and that a biopsy might yield a medical diagnosis. She stated, “If it were caught earlier and I was better able to tolerate treatment, it would make sense to know for sure, but now it doesn’t make sense. I just want to have no pain in my end.”
 

Misconceptions
In a study by Ganzini et al,^4,5 395 consultation−liaison psychiatrists, geriatricians, and geriatric psychologists responded to a survey in which they rated types of misunderstandings by clinicians who refer patients for assessment of decision-making capacity. Seventy percent reported that it is common that, when a patient has a mental illness such as schizophrenia, practitioners think that the patient lacks capacity to make medical decisions. However, results of a meta-analysis by Jeste et al,⁶ in which the magnitude of impairment of decisional capacity in patients with schizophrenia was assessed in comparison to that of normal subjects, suggest that the presence of schizophrenia does not necessarily mean the patient has impaired capacity.

Voluntary participation in research. Many patients with schizophrenia volunteer to participate in clinical trials even when they are acutely psychotic and admitted to a psychiatric hospital. Given the importance placed on participants’ voluntary informed consent as a prerequisite for ethical conduct of research, the cognitive and emotional impairments associated with schizophrenia raise questions about patients’ capacity to consent.

As is true in other areas of functional capacity, the ability of patients with schizophrenia to make competent decisions relates more to their overall cognitive functioning than to the presence or absence of specific symptoms of the disorder.⁷ Documentation of longitudinal consent-related abilities among research participants with schizophrenia in the long-term Clinical Antipsychotic Trials of Intervention Effectiveness study indicated that most participants had stable or improved consent-related abilities. Although almost 25% of participants experienced substantial worsening, only 4% fell below the study’s capacity threshold for enrollment.⁸

What I learned from Ms. V
A diagnosis of schizophrenia does not automatically render a person unable to make decisions about medical care. Even patients who have severe mental illness might have significant intact areas of reality testing. Ethically, it is important to at least consider that the chronically mentally ill can understand treatment options and express consistent choices.

Healthcare providers might tend to exclude psychiatric patients from end-of-life decisions because they (1) are worried about the emotional fragility of such patients and (2) assume that patients lack capacity to participate in making such important decisions. The case presented here is an example of a patient with a severe psychiatric diagnosis being able to participate in her care despite her mental state.

Some practitioners of medicine—including psychiatrists—might equate “psychosis” with incapacity, but that isn’t necessarily true. Even patients who, by most measures, are deemed psychotic might be capable of making wise and thoughtful decisions about their life. The case I describe in this article demonstrates that fact.

While rotating on a busy consultation service, I was asked to evaluate the capacity of a woman who had a diagnosis of schizophrenia and was being seen for worsening auditory hallucinations and progressive weight loss. She had a complicated medical course that eventually led to multiple requests to the consult team for a capacity evaluation.

The question of capacity in this patient, and in the psychiatric population generally, motivated me to review the literature, because the assumption by many on the medical teams involved in this patient’s care was that psychiatric patients do not have the capacity to participate in their own care. My goal here is to clarify the misconceptions in regard to this situation.

CASE REPORT
Schizophrenia, weight loss, back pain
Ms. V, age 67, a resident of a group home for the past 6 years, was brought to the emergency department (ED) because of weight loss and auditory hallucinations that had developed during the past few months. She had a history of paranoid schizophrenia that included several psychiatric hospitalizations but no known medical history.

The patient appeared cachectic and dehydrated. When approached, she was pleasant and reported hearing voices of the “devil.”

“They are not scary,” she confided. “They talk to me about art and literature.”

Over the past 6 months, Ms. V had lost 60 lb; she was now bedridden because of back pain. Collateral information obtained from staff members at the group home indicated that she had refused to get out of bed, and only intermittently took her medications or ate meals during the past few months. In general, however, she had been relatively stable over the course of her psychiatric illness, was adherent to psychiatric treatment, and had had no psychiatric hospitalizations in the past 3 decades.

Ominous development. Although the ED staff was convinced that Ms. V needed psychiatric admission, we (the consult team) first requested a detailed medical workup, including imaging studies. A CT scan showed multiple metastatic foci throughout her spine. She was admitted to the medical service.

Respiratory distress developed; her condition deteriorated. Numerous capacity consults were requested because she refused a medical workup or to sign do-not-resuscitate and do-not-intubate orders. Each time an evaluation was performed, Ms. V was deemed by various clinicians on the consult service to have decision-making capacity.

The patient grew unhappy with the staff’s insistence that she undergo more tests regardless of her stated wishes. The palliative care service determined that further workup would not benefit her medically: Ms. V’s condition would be grave and her prognosis poor regardless of what treatment she received.

The medical team continued to believe that, because that this patient had a mental illness and was actively hallucinating, she did not have the capacity to refuse any proposed treatments and tests.

What is capacity?
Capacity is an assessment of a person’s ability to make rational decisions. This includes the ability to understand, appreciate, and manipulate information in reaching such decisions. Determining whether a patient has the capacity to accept or refuse treatment is a medical decision that any physician can make; however, consultation−liaison psychiatrists are the experts who often are involved in this activity, particularly in patients who have a psychiatric comorbidity.

Capacity is evaluated by assessing 4 standards; that is, whether a patient can:

• communicate choice about proposed treatment
• understand her (his) medical situation
• appreciate the situation and its consequences
• manipulate information to reach a rational decision.^1-3
• manipulate information to reach a rational decision.
   

CASE REPORT continued
Although Ms. V’s health was deteriorating and her auditory hallucinations were becoming worse, she appeared insightful about her medical problems, understood her prognosis, and wanted comfort care. She understood that having multiple metastases meant a poor prognosis, and that a biopsy might yield a medical diagnosis. She stated, “If it were caught earlier and I was better able to tolerate treatment, it would make sense to know for sure, but now it doesn’t make sense. I just want to have no pain in my end.”
 

Misconceptions
In a study by Ganzini et al,^4,5 395 consultation−liaison psychiatrists, geriatricians, and geriatric psychologists responded to a survey in which they rated types of misunderstandings by clinicians who refer patients for assessment of decision-making capacity. Seventy percent reported that it is common that, when a patient has a mental illness such as schizophrenia, practitioners think that the patient lacks capacity to make medical decisions. However, results of a meta-analysis by Jeste et al,⁶ in which the magnitude of impairment of decisional capacity in patients with schizophrenia was assessed in comparison to that of normal subjects, suggest that the presence of schizophrenia does not necessarily mean the patient has impaired capacity.

Voluntary participation in research. Many patients with schizophrenia volunteer to participate in clinical trials even when they are acutely psychotic and admitted to a psychiatric hospital. Given the importance placed on participants’ voluntary informed consent as a prerequisite for ethical conduct of research, the cognitive and emotional impairments associated with schizophrenia raise questions about patients’ capacity to consent.

As is true in other areas of functional capacity, the ability of patients with schizophrenia to make competent decisions relates more to their overall cognitive functioning than to the presence or absence of specific symptoms of the disorder.⁷ Documentation of longitudinal consent-related abilities among research participants with schizophrenia in the long-term Clinical Antipsychotic Trials of Intervention Effectiveness study indicated that most participants had stable or improved consent-related abilities. Although almost 25% of participants experienced substantial worsening, only 4% fell below the study’s capacity threshold for enrollment.⁸

What I learned from Ms. V
A diagnosis of schizophrenia does not automatically render a person unable to make decisions about medical care. Even patients who have severe mental illness might have significant intact areas of reality testing. Ethically, it is important to at least consider that the chronically mentally ill can understand treatment options and express consistent choices.

Healthcare providers might tend to exclude psychiatric patients from end-of-life decisions because they (1) are worried about the emotional fragility of such patients and (2) assume that patients lack capacity to participate in making such important decisions. The case presented here is an example of a patient with a severe psychiatric diagnosis being able to participate in her care despite her mental state.

As dermatology residents, the telephone calls we get at 2 am usually are the toughest for 2 reasons: (1) we rarely get calls at 2 am, and (2) it usually means there is a case to rule out Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Stevens-Johnson syndrome and TEN are severe mucocutaneous eruptions that usually develop due to drug reactions and involve a continuum of conjunctivitis, mucocutaneous sloughing, keratinocyte death, and bullae development. Body surface area (BSA) coverage determines the distinction between SJS and TEN; less than 10% BSA affected indicates SJS, 10% to 30% BSA affected indicates overlap between SJS and TEN, and greater than 30% BSA affected indicates TEN.¹ The mortality rates for these conditions range from 1% to 5% in SJS versus 25% to 30% in TEN.²

Being driven and dedicated residents, we rise to the challenge by arranging appropriate consultations, obtaining frozen section biopsies, providing recommendations to remove unnecessary medications, and offering skin care management. However, what comes next? Intravenous immunoglobulin (IVIG)? Cyclosporine? Or is it appropriate to allow the reaction to continue its course? Dermatology programs have a varying standard of care due to the limited number of studies conducted on SJS/TEN patients. Few studies have relayed the efficacy of cyclosporine; however, published results have shown that cyclosporine can decrease the overall mortality risk and minimize disease progression.^2-5 In this article, I will review some of the key studies conducted in the last 5 years regarding the use of cyclosporine in the therapeutic plan for SJS/TEN.

In one retrospective analysis conducted by Kirchhof et al¹ in 2014, 35 patients with SJS/TEN who were treated with IVIG and 15 who were treated with cyclosporine were evaluated for mortality benefit. Two patients were treated with both cyclosporine and IVIG and were included in both arms of the study. Overall, the evaluation indicated that cyclosporine can potentially have a better overall advantage in treatment of SJS/TEN over IVIG.¹ Although this study had an uneven number of patients treated with IVIG versus cyclosporine, a nonstandardized way of comparing patients with early SJS to TEN patients, and no double-blind randomized trial, cyclosporine may still show benefit over IVIG.

Singh et al⁶ conducted an uncontrolled open study in a tertiary care center (July 2011–June 2012) that showed a similar result of benefit with cyclosporine in SJS, SJS/TEN, and TEN patients. Eleven participants were included in the study based on SCORTEN (Score of Toxic Epidermal Necrosis) criteria (age, >40 years; heart rate, >120 BPM; serum blood urea nitrogen level, >28 mg/dL; body surface area affected, >10%; serum bicarbonate, >20 mEq/L; serum glucose, >252 mg/dL). They were treated with cyclosporine 3 mg/kg for 7 days and then tapered over another 7 days. Six participants were treated with corticosteroids. Participants treated with cyclosporine reepithelialized in 16.7 days compared to 23 days with corticosteroids. The hospital stay was 18.09 days in participants treated with cyclosporine versus 26 days in those treated with corticosteroids. Lastly, 2 participants who were treated with corticosteroids died as opposed to none with cyclosporine.⁶ Although the power of this study also was limited and it was not a randomized, double-blind, controlled trial, it provides more evidence that cyclosporine can be efficacious in SJS/TEN patients.

A phase 2 open trial conducted by Valeyrie-Allanore et al⁷ evaluated the benefit and efficacy of cyclosporine in SJS/TEN patients. There were 29 participants at the start of the study (SJS, n=10; SJS/TEN, n=12; TEN, n=7) and 26 completed treatment. Cyclosporine was administered orally at 3 mg/kg for 10 days and tapered over the following month. This study noted 3 basic principles: First, patients tolerated cyclosporine well; second, limited disease progression was noted in 62% (18/29) of participants around day 3 and in only about 35% (11/29) of IVIG patients; and third, no deaths were noted in all participants.⁷

Final Thoughts

Case reports have indicated that cyclosporine may be effective in limiting progression of SJS/TEN; however, a double-blind study has not validated this finding. Hence, patients should be evaluated on a case-by-case basis to determine if they should be treated with cyclosporine or IVIG or simply complete the course of the disease process with supportive care.

As dermatology residents, the telephone calls we get at 2 am usually are the toughest for 2 reasons: (1) we rarely get calls at 2 am, and (2) it usually means there is a case to rule out Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Stevens-Johnson syndrome and TEN are severe mucocutaneous eruptions that usually develop due to drug reactions and involve a continuum of conjunctivitis, mucocutaneous sloughing, keratinocyte death, and bullae development. Body surface area (BSA) coverage determines the distinction between SJS and TEN; less than 10% BSA affected indicates SJS, 10% to 30% BSA affected indicates overlap between SJS and TEN, and greater than 30% BSA affected indicates TEN.¹ The mortality rates for these conditions range from 1% to 5% in SJS versus 25% to 30% in TEN.²

Being driven and dedicated residents, we rise to the challenge by arranging appropriate consultations, obtaining frozen section biopsies, providing recommendations to remove unnecessary medications, and offering skin care management. However, what comes next? Intravenous immunoglobulin (IVIG)? Cyclosporine? Or is it appropriate to allow the reaction to continue its course? Dermatology programs have a varying standard of care due to the limited number of studies conducted on SJS/TEN patients. Few studies have relayed the efficacy of cyclosporine; however, published results have shown that cyclosporine can decrease the overall mortality risk and minimize disease progression.^2-5 In this article, I will review some of the key studies conducted in the last 5 years regarding the use of cyclosporine in the therapeutic plan for SJS/TEN.

In one retrospective analysis conducted by Kirchhof et al¹ in 2014, 35 patients with SJS/TEN who were treated with IVIG and 15 who were treated with cyclosporine were evaluated for mortality benefit. Two patients were treated with both cyclosporine and IVIG and were included in both arms of the study. Overall, the evaluation indicated that cyclosporine can potentially have a better overall advantage in treatment of SJS/TEN over IVIG.¹ Although this study had an uneven number of patients treated with IVIG versus cyclosporine, a nonstandardized way of comparing patients with early SJS to TEN patients, and no double-blind randomized trial, cyclosporine may still show benefit over IVIG.

Singh et al⁶ conducted an uncontrolled open study in a tertiary care center (July 2011–June 2012) that showed a similar result of benefit with cyclosporine in SJS, SJS/TEN, and TEN patients. Eleven participants were included in the study based on SCORTEN (Score of Toxic Epidermal Necrosis) criteria (age, >40 years; heart rate, >120 BPM; serum blood urea nitrogen level, >28 mg/dL; body surface area affected, >10%; serum bicarbonate, >20 mEq/L; serum glucose, >252 mg/dL). They were treated with cyclosporine 3 mg/kg for 7 days and then tapered over another 7 days. Six participants were treated with corticosteroids. Participants treated with cyclosporine reepithelialized in 16.7 days compared to 23 days with corticosteroids. The hospital stay was 18.09 days in participants treated with cyclosporine versus 26 days in those treated with corticosteroids. Lastly, 2 participants who were treated with corticosteroids died as opposed to none with cyclosporine.⁶ Although the power of this study also was limited and it was not a randomized, double-blind, controlled trial, it provides more evidence that cyclosporine can be efficacious in SJS/TEN patients.

A phase 2 open trial conducted by Valeyrie-Allanore et al⁷ evaluated the benefit and efficacy of cyclosporine in SJS/TEN patients. There were 29 participants at the start of the study (SJS, n=10; SJS/TEN, n=12; TEN, n=7) and 26 completed treatment. Cyclosporine was administered orally at 3 mg/kg for 10 days and tapered over the following month. This study noted 3 basic principles: First, patients tolerated cyclosporine well; second, limited disease progression was noted in 62% (18/29) of participants around day 3 and in only about 35% (11/29) of IVIG patients; and third, no deaths were noted in all participants.⁷

Final Thoughts

Case reports have indicated that cyclosporine may be effective in limiting progression of SJS/TEN; however, a double-blind study has not validated this finding. Hence, patients should be evaluated on a case-by-case basis to determine if they should be treated with cyclosporine or IVIG or simply complete the course of the disease process with supportive care.

As dermatology residents, the telephone calls we get at 2 am usually are the toughest for 2 reasons: (1) we rarely get calls at 2 am, and (2) it usually means there is a case to rule out Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Stevens-Johnson syndrome and TEN are severe mucocutaneous eruptions that usually develop due to drug reactions and involve a continuum of conjunctivitis, mucocutaneous sloughing, keratinocyte death, and bullae development. Body surface area (BSA) coverage determines the distinction between SJS and TEN; less than 10% BSA affected indicates SJS, 10% to 30% BSA affected indicates overlap between SJS and TEN, and greater than 30% BSA affected indicates TEN.¹ The mortality rates for these conditions range from 1% to 5% in SJS versus 25% to 30% in TEN.²

Being driven and dedicated residents, we rise to the challenge by arranging appropriate consultations, obtaining frozen section biopsies, providing recommendations to remove unnecessary medications, and offering skin care management. However, what comes next? Intravenous immunoglobulin (IVIG)? Cyclosporine? Or is it appropriate to allow the reaction to continue its course? Dermatology programs have a varying standard of care due to the limited number of studies conducted on SJS/TEN patients. Few studies have relayed the efficacy of cyclosporine; however, published results have shown that cyclosporine can decrease the overall mortality risk and minimize disease progression.^2-5 In this article, I will review some of the key studies conducted in the last 5 years regarding the use of cyclosporine in the therapeutic plan for SJS/TEN.

In one retrospective analysis conducted by Kirchhof et al¹ in 2014, 35 patients with SJS/TEN who were treated with IVIG and 15 who were treated with cyclosporine were evaluated for mortality benefit. Two patients were treated with both cyclosporine and IVIG and were included in both arms of the study. Overall, the evaluation indicated that cyclosporine can potentially have a better overall advantage in treatment of SJS/TEN over IVIG.¹ Although this study had an uneven number of patients treated with IVIG versus cyclosporine, a nonstandardized way of comparing patients with early SJS to TEN patients, and no double-blind randomized trial, cyclosporine may still show benefit over IVIG.

Singh et al⁶ conducted an uncontrolled open study in a tertiary care center (July 2011–June 2012) that showed a similar result of benefit with cyclosporine in SJS, SJS/TEN, and TEN patients. Eleven participants were included in the study based on SCORTEN (Score of Toxic Epidermal Necrosis) criteria (age, >40 years; heart rate, >120 BPM; serum blood urea nitrogen level, >28 mg/dL; body surface area affected, >10%; serum bicarbonate, >20 mEq/L; serum glucose, >252 mg/dL). They were treated with cyclosporine 3 mg/kg for 7 days and then tapered over another 7 days. Six participants were treated with corticosteroids. Participants treated with cyclosporine reepithelialized in 16.7 days compared to 23 days with corticosteroids. The hospital stay was 18.09 days in participants treated with cyclosporine versus 26 days in those treated with corticosteroids. Lastly, 2 participants who were treated with corticosteroids died as opposed to none with cyclosporine.⁶ Although the power of this study also was limited and it was not a randomized, double-blind, controlled trial, it provides more evidence that cyclosporine can be efficacious in SJS/TEN patients.

A phase 2 open trial conducted by Valeyrie-Allanore et al⁷ evaluated the benefit and efficacy of cyclosporine in SJS/TEN patients. There were 29 participants at the start of the study (SJS, n=10; SJS/TEN, n=12; TEN, n=7) and 26 completed treatment. Cyclosporine was administered orally at 3 mg/kg for 10 days and tapered over the following month. This study noted 3 basic principles: First, patients tolerated cyclosporine well; second, limited disease progression was noted in 62% (18/29) of participants around day 3 and in only about 35% (11/29) of IVIG patients; and third, no deaths were noted in all participants.⁷

Final Thoughts

Case reports have indicated that cyclosporine may be effective in limiting progression of SJS/TEN; however, a double-blind study has not validated this finding. Hence, patients should be evaluated on a case-by-case basis to determine if they should be treated with cyclosporine or IVIG or simply complete the course of the disease process with supportive care.

The Orthopaedic Sports Medicine Fellowship Match was first established in 2008 as a joint-sponsored venture between the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America to pair applicants with participating training programs.¹ Operated under the San Francisco Match,² the current fellowship match process was adopted to systematically coordinate training appointments and eliminate the role of “exploding offers,” which are pressured early decisions predicated on immediate acceptance. Other advantages of this system include its operation through a central application service to avoid redundancy of submitted paperwork, as well as to create greater awareness and to publicize training options and standardization of the match timeline.¹

In its current state, the orthopedic sports medicine match represents 96 programs with 230 positions, accounting for approximately 97% of training programs and fellowship positions.¹ While unaccredited options remain available through the Match, many programs have migrated towards American Council for Graduate Medical Education (ACGME) accreditation because of an increased focus on objective learning metrics during fellowship and the requirement for Subspecialty Certification in Orthopaedic Sports Medicine through the American Board of Orthopaedic Surgery.³ However, other programs have also eschewed the increasing constraints and administrative resources associated with ACGME accreditation, particularly among fellowships based at community-based hospitals or private practices that lack formal affiliation with academic institutions or residency training programs.

Along with a greater understanding of the historical background of the match process, fellowship applicants must also appreciate the relative merits of fellowship training. More than 90% of orthopedic surgery residents now pursue further subspecialty fellowship training, with some individuals opting for 2 additional fellowship opportunities.⁴ As a so-called “nontraditional applicant,” I represent a different demographic, returning to fellowship after years of clinical practice while serving in the military. Individual preferences notwithstanding, I wanted to take the opportunity to emphasize some important considerations in deliberating between different fellowship programs.

• Geography. Your eventual desired practice location may play a role in determining fellowship location or, at least, region of the country. Additionally, this can be an important factor in family happiness. In competitive markets, such as the Northeast or the West Coast, you may make inroads and establish professional connections that result in potential job opportunities. Conversely, other programs may adopt anticompetitive measures to limit local practice options.
• Training setting. Despite the trending consolidation of fellowship training programs in affiliated university and hospital-based teaching systems, many community-based programs and private-practice models thrive, providing an alternative to traditional academic training centers. The latter may provide more in-depth exposure to practice management, billing/coding, and ancillary services. The former typically offer a more structured, academically oriented environment with formal teaching conferences and a broader department hierarchy.
• Program size. Some applicants may prefer a larger, more diverse array of teaching staff or fellows, while others gravitate toward fewer, more personal mentoring relationships that allow more intimate familiarity with practice habits or surgical techniques.
• Associated training programs. Affiliations with a residency or physician-extender training program can offer benefits and drawbacks, including offloading clerical work, shared hands-on experience in the clinic and operating room, and midlevel supervisory responsibilities. This can offer useful opportunities to formulate an individual teaching style and valuable mentoring relationships. However, it can also impose greater time requirements or detract from one-on-one teaching with staff.
• Reputation. Applicants may attach distinction to a well-established regional or national reputation associated with a given training program. Often, certain programs may carry prestige as a result of their academic name, hospital affiliation, or accomplishments. This can offer certain marketing advantages for patient recruitment. However, less renowned programs may provide better training opportunities and confer higher esteem among your professional colleagues. Program reputation can change dramatically with time, so this should be balanced with other potential strengths and overall training experience.
• Practice “niches”/areas of interest. With increasing adoption of arthroscopic techniques among practicing surgeons and a relative excess of sports medicine–trained orthopedists, it is paramount to develop a novel skill set during fellowship to differentiate you from other graduates. I sought a sports medicine fellowship that would offer me a broad-based exposure to arthroscopic and open knee and shoulder reconstruction, chondral restoration techniques, hip arthroscopy and preservation, and shoulder arthroplasty. Opportunities in elbow reconstruction, foot and ankle arthroscopy, and pediatric sports medicine may also be valuable as a distinguishing factor in searching for jobs after training.
• Marketability. Closely intertwined with reputation and scope of practice, an institution’s marketability is another intangible attribute to consider. Professional or collegiate team coverage offers significant market value for patient advertising, and it is frequently publicized by orthopedic practices and hospital systems. Additionally, the importance of ACGME accreditation should also be considered.
• Nonmedical training. This is increasingly important in subsequent subspecialty training. Further education on the business aspects of orthopedic surgery should be emphasized. Additionally, dedicated curricula on professional or leadership development are important for career progression.
• Mentorship. Throughout the interview process, one of my foremost priorities was a strong and enduring pattern of mentorship. Fellowship offers the opportunity to establish 1 or multiple mentors in your subspecialty. These individuals will be instrumental in the development of your early professional career and your approach to clinical practice. From discussions about complicated patients to advice on contract negotiations, your ideal mentor should champion your early successes and work generously on your behalf, even long after fellowship has ended. 

• Research opportunities. Given my academic career goals, I actively pursued a program with rich clinical and laboratory resources, and an established infrastructure for accomplishing high-quality, relevant research. Interested individuals should gauge the availability of research support staff, biomechanical or bench-level laboratory collaboration, grant or institutional research funding, cadaveric specimens, or clinical outcomes data for research conducted by fellows. However, not all fellowship applicants have a vested interest in research during fellowship, so I would encourage inquiries regarding core research requirements and expectations.
• Clinical exposure. This encompasses several different and equally important variables, including diversity of clinical or surgical caseloads, case complexity, operative exposure, athletic team coverage, and office or clinical experience. Interestingly, this latter aspect of training is often neglected but cannot be overemphasized. Outpatient clinical evaluation is key to honing important physical examination techniques and critically evaluating patients’ outcomes postoperatively.
• Surgical autonomy. Hands-on operative experience and surgical autonomy vary widely among fellowship programs. Most fellowships advocate for a graduated level of surgical responsibility dependent on individual abilities and staff comfort, while others offer greater potential for independence. Conversely, some programs espouse more of an “observership” model, and arthroscopic simulators and/or cadaveric skills laboratories are designed to complement operative experience. While most fellowship applicants desire maximal case participation, we must also recognize the value in watching talented surgeons performing technically demanding procedures.
• Family. You cannot put a premium on your personal contentment and family’s well-being. Proximity to a support network can be important with the work demands and time constraints of fellowship.

Despite financial obligations and significant time commitments, the fellowship match process offers an incredible range of programs and practice environments. Inevitably, no program can completely fulfill all your criteria, but you should be able to tailor your learning style, professional ambitions, and personal preferences with an excellent training program. For many, fellowship represents the last, and perhaps most integral, stage of formal surgical training. Considering all factors of your chosen fellowship program will ensure a rich and fulfilling educational experience.

The Orthopaedic Sports Medicine Fellowship Match was first established in 2008 as a joint-sponsored venture between the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America to pair applicants with participating training programs.¹ Operated under the San Francisco Match,² the current fellowship match process was adopted to systematically coordinate training appointments and eliminate the role of “exploding offers,” which are pressured early decisions predicated on immediate acceptance. Other advantages of this system include its operation through a central application service to avoid redundancy of submitted paperwork, as well as to create greater awareness and to publicize training options and standardization of the match timeline.¹

In its current state, the orthopedic sports medicine match represents 96 programs with 230 positions, accounting for approximately 97% of training programs and fellowship positions.¹ While unaccredited options remain available through the Match, many programs have migrated towards American Council for Graduate Medical Education (ACGME) accreditation because of an increased focus on objective learning metrics during fellowship and the requirement for Subspecialty Certification in Orthopaedic Sports Medicine through the American Board of Orthopaedic Surgery.³ However, other programs have also eschewed the increasing constraints and administrative resources associated with ACGME accreditation, particularly among fellowships based at community-based hospitals or private practices that lack formal affiliation with academic institutions or residency training programs.

Along with a greater understanding of the historical background of the match process, fellowship applicants must also appreciate the relative merits of fellowship training. More than 90% of orthopedic surgery residents now pursue further subspecialty fellowship training, with some individuals opting for 2 additional fellowship opportunities.⁴ As a so-called “nontraditional applicant,” I represent a different demographic, returning to fellowship after years of clinical practice while serving in the military. Individual preferences notwithstanding, I wanted to take the opportunity to emphasize some important considerations in deliberating between different fellowship programs.

• Geography. Your eventual desired practice location may play a role in determining fellowship location or, at least, region of the country. Additionally, this can be an important factor in family happiness. In competitive markets, such as the Northeast or the West Coast, you may make inroads and establish professional connections that result in potential job opportunities. Conversely, other programs may adopt anticompetitive measures to limit local practice options.
• Training setting. Despite the trending consolidation of fellowship training programs in affiliated university and hospital-based teaching systems, many community-based programs and private-practice models thrive, providing an alternative to traditional academic training centers. The latter may provide more in-depth exposure to practice management, billing/coding, and ancillary services. The former typically offer a more structured, academically oriented environment with formal teaching conferences and a broader department hierarchy.
• Program size. Some applicants may prefer a larger, more diverse array of teaching staff or fellows, while others gravitate toward fewer, more personal mentoring relationships that allow more intimate familiarity with practice habits or surgical techniques.
• Associated training programs. Affiliations with a residency or physician-extender training program can offer benefits and drawbacks, including offloading clerical work, shared hands-on experience in the clinic and operating room, and midlevel supervisory responsibilities. This can offer useful opportunities to formulate an individual teaching style and valuable mentoring relationships. However, it can also impose greater time requirements or detract from one-on-one teaching with staff.
• Reputation. Applicants may attach distinction to a well-established regional or national reputation associated with a given training program. Often, certain programs may carry prestige as a result of their academic name, hospital affiliation, or accomplishments. This can offer certain marketing advantages for patient recruitment. However, less renowned programs may provide better training opportunities and confer higher esteem among your professional colleagues. Program reputation can change dramatically with time, so this should be balanced with other potential strengths and overall training experience.
• Practice “niches”/areas of interest. With increasing adoption of arthroscopic techniques among practicing surgeons and a relative excess of sports medicine–trained orthopedists, it is paramount to develop a novel skill set during fellowship to differentiate you from other graduates. I sought a sports medicine fellowship that would offer me a broad-based exposure to arthroscopic and open knee and shoulder reconstruction, chondral restoration techniques, hip arthroscopy and preservation, and shoulder arthroplasty. Opportunities in elbow reconstruction, foot and ankle arthroscopy, and pediatric sports medicine may also be valuable as a distinguishing factor in searching for jobs after training.
• Marketability. Closely intertwined with reputation and scope of practice, an institution’s marketability is another intangible attribute to consider. Professional or collegiate team coverage offers significant market value for patient advertising, and it is frequently publicized by orthopedic practices and hospital systems. Additionally, the importance of ACGME accreditation should also be considered.
• Nonmedical training. This is increasingly important in subsequent subspecialty training. Further education on the business aspects of orthopedic surgery should be emphasized. Additionally, dedicated curricula on professional or leadership development are important for career progression.
• Mentorship. Throughout the interview process, one of my foremost priorities was a strong and enduring pattern of mentorship. Fellowship offers the opportunity to establish 1 or multiple mentors in your subspecialty. These individuals will be instrumental in the development of your early professional career and your approach to clinical practice. From discussions about complicated patients to advice on contract negotiations, your ideal mentor should champion your early successes and work generously on your behalf, even long after fellowship has ended. 

• Research opportunities. Given my academic career goals, I actively pursued a program with rich clinical and laboratory resources, and an established infrastructure for accomplishing high-quality, relevant research. Interested individuals should gauge the availability of research support staff, biomechanical or bench-level laboratory collaboration, grant or institutional research funding, cadaveric specimens, or clinical outcomes data for research conducted by fellows. However, not all fellowship applicants have a vested interest in research during fellowship, so I would encourage inquiries regarding core research requirements and expectations.
• Clinical exposure. This encompasses several different and equally important variables, including diversity of clinical or surgical caseloads, case complexity, operative exposure, athletic team coverage, and office or clinical experience. Interestingly, this latter aspect of training is often neglected but cannot be overemphasized. Outpatient clinical evaluation is key to honing important physical examination techniques and critically evaluating patients’ outcomes postoperatively.
• Surgical autonomy. Hands-on operative experience and surgical autonomy vary widely among fellowship programs. Most fellowships advocate for a graduated level of surgical responsibility dependent on individual abilities and staff comfort, while others offer greater potential for independence. Conversely, some programs espouse more of an “observership” model, and arthroscopic simulators and/or cadaveric skills laboratories are designed to complement operative experience. While most fellowship applicants desire maximal case participation, we must also recognize the value in watching talented surgeons performing technically demanding procedures.
• Family. You cannot put a premium on your personal contentment and family’s well-being. Proximity to a support network can be important with the work demands and time constraints of fellowship.

Despite financial obligations and significant time commitments, the fellowship match process offers an incredible range of programs and practice environments. Inevitably, no program can completely fulfill all your criteria, but you should be able to tailor your learning style, professional ambitions, and personal preferences with an excellent training program. For many, fellowship represents the last, and perhaps most integral, stage of formal surgical training. Considering all factors of your chosen fellowship program will ensure a rich and fulfilling educational experience.

The Orthopaedic Sports Medicine Fellowship Match was first established in 2008 as a joint-sponsored venture between the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America to pair applicants with participating training programs.¹ Operated under the San Francisco Match,² the current fellowship match process was adopted to systematically coordinate training appointments and eliminate the role of “exploding offers,” which are pressured early decisions predicated on immediate acceptance. Other advantages of this system include its operation through a central application service to avoid redundancy of submitted paperwork, as well as to create greater awareness and to publicize training options and standardization of the match timeline.¹

In its current state, the orthopedic sports medicine match represents 96 programs with 230 positions, accounting for approximately 97% of training programs and fellowship positions.¹ While unaccredited options remain available through the Match, many programs have migrated towards American Council for Graduate Medical Education (ACGME) accreditation because of an increased focus on objective learning metrics during fellowship and the requirement for Subspecialty Certification in Orthopaedic Sports Medicine through the American Board of Orthopaedic Surgery.³ However, other programs have also eschewed the increasing constraints and administrative resources associated with ACGME accreditation, particularly among fellowships based at community-based hospitals or private practices that lack formal affiliation with academic institutions or residency training programs.

Along with a greater understanding of the historical background of the match process, fellowship applicants must also appreciate the relative merits of fellowship training. More than 90% of orthopedic surgery residents now pursue further subspecialty fellowship training, with some individuals opting for 2 additional fellowship opportunities.⁴ As a so-called “nontraditional applicant,” I represent a different demographic, returning to fellowship after years of clinical practice while serving in the military. Individual preferences notwithstanding, I wanted to take the opportunity to emphasize some important considerations in deliberating between different fellowship programs.

• Geography. Your eventual desired practice location may play a role in determining fellowship location or, at least, region of the country. Additionally, this can be an important factor in family happiness. In competitive markets, such as the Northeast or the West Coast, you may make inroads and establish professional connections that result in potential job opportunities. Conversely, other programs may adopt anticompetitive measures to limit local practice options.
• Training setting. Despite the trending consolidation of fellowship training programs in affiliated university and hospital-based teaching systems, many community-based programs and private-practice models thrive, providing an alternative to traditional academic training centers. The latter may provide more in-depth exposure to practice management, billing/coding, and ancillary services. The former typically offer a more structured, academically oriented environment with formal teaching conferences and a broader department hierarchy.
• Program size. Some applicants may prefer a larger, more diverse array of teaching staff or fellows, while others gravitate toward fewer, more personal mentoring relationships that allow more intimate familiarity with practice habits or surgical techniques.
• Associated training programs. Affiliations with a residency or physician-extender training program can offer benefits and drawbacks, including offloading clerical work, shared hands-on experience in the clinic and operating room, and midlevel supervisory responsibilities. This can offer useful opportunities to formulate an individual teaching style and valuable mentoring relationships. However, it can also impose greater time requirements or detract from one-on-one teaching with staff.
• Reputation. Applicants may attach distinction to a well-established regional or national reputation associated with a given training program. Often, certain programs may carry prestige as a result of their academic name, hospital affiliation, or accomplishments. This can offer certain marketing advantages for patient recruitment. However, less renowned programs may provide better training opportunities and confer higher esteem among your professional colleagues. Program reputation can change dramatically with time, so this should be balanced with other potential strengths and overall training experience.
• Practice “niches”/areas of interest. With increasing adoption of arthroscopic techniques among practicing surgeons and a relative excess of sports medicine–trained orthopedists, it is paramount to develop a novel skill set during fellowship to differentiate you from other graduates. I sought a sports medicine fellowship that would offer me a broad-based exposure to arthroscopic and open knee and shoulder reconstruction, chondral restoration techniques, hip arthroscopy and preservation, and shoulder arthroplasty. Opportunities in elbow reconstruction, foot and ankle arthroscopy, and pediatric sports medicine may also be valuable as a distinguishing factor in searching for jobs after training.
• Marketability. Closely intertwined with reputation and scope of practice, an institution’s marketability is another intangible attribute to consider. Professional or collegiate team coverage offers significant market value for patient advertising, and it is frequently publicized by orthopedic practices and hospital systems. Additionally, the importance of ACGME accreditation should also be considered.
• Nonmedical training. This is increasingly important in subsequent subspecialty training. Further education on the business aspects of orthopedic surgery should be emphasized. Additionally, dedicated curricula on professional or leadership development are important for career progression.
• Mentorship. Throughout the interview process, one of my foremost priorities was a strong and enduring pattern of mentorship. Fellowship offers the opportunity to establish 1 or multiple mentors in your subspecialty. These individuals will be instrumental in the development of your early professional career and your approach to clinical practice. From discussions about complicated patients to advice on contract negotiations, your ideal mentor should champion your early successes and work generously on your behalf, even long after fellowship has ended. 

• Research opportunities. Given my academic career goals, I actively pursued a program with rich clinical and laboratory resources, and an established infrastructure for accomplishing high-quality, relevant research. Interested individuals should gauge the availability of research support staff, biomechanical or bench-level laboratory collaboration, grant or institutional research funding, cadaveric specimens, or clinical outcomes data for research conducted by fellows. However, not all fellowship applicants have a vested interest in research during fellowship, so I would encourage inquiries regarding core research requirements and expectations.
• Clinical exposure. This encompasses several different and equally important variables, including diversity of clinical or surgical caseloads, case complexity, operative exposure, athletic team coverage, and office or clinical experience. Interestingly, this latter aspect of training is often neglected but cannot be overemphasized. Outpatient clinical evaluation is key to honing important physical examination techniques and critically evaluating patients’ outcomes postoperatively.
• Surgical autonomy. Hands-on operative experience and surgical autonomy vary widely among fellowship programs. Most fellowships advocate for a graduated level of surgical responsibility dependent on individual abilities and staff comfort, while others offer greater potential for independence. Conversely, some programs espouse more of an “observership” model, and arthroscopic simulators and/or cadaveric skills laboratories are designed to complement operative experience. While most fellowship applicants desire maximal case participation, we must also recognize the value in watching talented surgeons performing technically demanding procedures.
• Family. You cannot put a premium on your personal contentment and family’s well-being. Proximity to a support network can be important with the work demands and time constraints of fellowship.

Despite financial obligations and significant time commitments, the fellowship match process offers an incredible range of programs and practice environments. Inevitably, no program can completely fulfill all your criteria, but you should be able to tailor your learning style, professional ambitions, and personal preferences with an excellent training program. For many, fellowship represents the last, and perhaps most integral, stage of formal surgical training. Considering all factors of your chosen fellowship program will ensure a rich and fulfilling educational experience.

CASE REPORT Evaluation for renal transplant

Mr. B, age 21, who has a diagnosis of autism spectrum disorder and an IQ comparable to that of a 4-year-old, is referred for evaluation of his candidacy for renal transplant.

A few months earlier, Mr. B pulled out his temporary dialysis catheter. Now, he receives hemodialysis through an arteriovenous fistula in the arm, but requires constant supervision during dialysis.

At evaluation, Mr. B is accompanied by his parents and his older sister, who have been providing day-to-day care for him. They appear fully committed to his well-being.

Mr. B does not have a living donor.

Needed: Assessment of adaptive functioning
DSM-5 defines intellectual disability as a disorder with onset during the developmental period. It includes deficits of intellectual and adaptive functioning in conceptual, social, and practical domains.

Regrettably, many authors focus exclusively on intellectual functioning and IQ, classifying patients as having intellectual disability based on intelligence tests alone.^1,2 Adaptive capabilities are insufficiently taken into consideration; there is an urgent need to supplement IQ testing with neuropsychological testing of a patient’s cognitive and adaptive functioning.

Landmark case
In 1995, Sandra Jensen, age 34, with trisomy 21 (Down syndrome) was denied a heart and lung transplant at 2 prominent academic institutions. The denial created a national debate; Jensen’s advocates persuaded one of the hospitals to reconsider.^3,4 

In 1996, Jensen received the transplant, but she died 18 months later from complications of immunosuppressive therapy. Her surgery was a landmark event; previously, no patient with trisomy 21 or intellectual disability had undergone organ transplantation.

Although attitudes and practices have changed in the past 2 decades, intellectual disability is still considered a relative contraindication to certain organ transplants.⁵

Why is intellectual disability still a contraindication?
Allocation of transplant organs is based primarily on the ethical principle of utilitarianism: ie, a morally good action is one that helps the greatest number of people. “Benefit” might take the form of the number of lives saved or the number of years added to a patient’s life.

There is little consensus on the definition of quality of life, with its debatable ideological standpoint that stands, at times, in contrast to distributive justice. Studies have shown that the long-term outcome for patients with intellectual disability who received a kidney transplant is comparable to the outcome after renal transplant for patients who are not intellectually disabled. In other studies, patients with intellectual disability and their caregivers report improvement in quality of life after transplant.

The goal of successful transplantation is improvement in quality of life and an increase in longevity. Compliance with all aspects of post-transplant treatment is essential—which is why intellectual disability remains a relative contraindication to heart transplantation in the guidelines of the International Society for Heart and Lung Transplantation. The society’s position is based on a theoretical rationale: ie, “concerns about compliance.”

Only 7 cases of successful long-term outcome after cardiac transplantation have been reported in patients with intellectual disability, and these were marked by the presence of the social and cognitive support necessary for post-transplant compliance with treatment.⁵ One of these 7 patients had a lengthy hospitalization 4 years after transplantation because of poor adherence to his medication regimen, following the functional decline of his primary caregiver.

Two-pronged evaluation is needed. Most patients undergoing organ transplantation receive a psychosocial assessment that varies from institution to institution. Intellectual disability can add complexity to the task of assessing candidacy for transplantation, however. In these patients, the availability and adequacy of caregivers is as important a part of decision-making as assessment of the patients themselves—yet studies of the assessment of caregivers are limited. The patient’s caregivers should be present during evaluation so that their knowledge, ability, and willingness to take on post-transplant responsibilities can be assessed. More research is needed on long-term outcomes of successful transplantation in patients with intellectual disability.

CASE CONTINUED Placement on hold
The transplant committee decides to postpone placing Mr. B on the transplant waiting list. Consensus is to revisit the question of placing him on the list at a later date.

What led to this decision?
The committee had several concerns about approving Mr. B for a transplant:

• His history of pulling out the catheter meant that he would require closer postoperative monitoring, because he would likely have drains and a urinary catheter inserted.
• Maintaining adequate oral hydration with a new kidney could be a challenge because Mr. B would not be able to comprehend how dehydration can destroy a new kidney.
• His parents believed that, after transplant, Mr. B would not be dependent on them; they failed to understand that he requires lifelong supervision to ensure compliance with immunosuppressive medications and return for follow-up.

The committee’s decision was aided by the rationale that dialysis is readily available and is a sustainable alternative to transplantation.

Mr. B’s case raises an ethical question
We speculate what the team’s decision about transplantation would have been if Mr. B (1) had a living donor or (2) was being considered for a heart, lung, or liver transplant—for which there is no analogous procedure to dialysis to sustain the patient.

CASE REPORT Evaluation for renal transplant

Mr. B, age 21, who has a diagnosis of autism spectrum disorder and an IQ comparable to that of a 4-year-old, is referred for evaluation of his candidacy for renal transplant.

A few months earlier, Mr. B pulled out his temporary dialysis catheter. Now, he receives hemodialysis through an arteriovenous fistula in the arm, but requires constant supervision during dialysis.

At evaluation, Mr. B is accompanied by his parents and his older sister, who have been providing day-to-day care for him. They appear fully committed to his well-being.

Mr. B does not have a living donor.

Needed: Assessment of adaptive functioning
DSM-5 defines intellectual disability as a disorder with onset during the developmental period. It includes deficits of intellectual and adaptive functioning in conceptual, social, and practical domains.

Regrettably, many authors focus exclusively on intellectual functioning and IQ, classifying patients as having intellectual disability based on intelligence tests alone.^1,2 Adaptive capabilities are insufficiently taken into consideration; there is an urgent need to supplement IQ testing with neuropsychological testing of a patient’s cognitive and adaptive functioning.

Landmark case
In 1995, Sandra Jensen, age 34, with trisomy 21 (Down syndrome) was denied a heart and lung transplant at 2 prominent academic institutions. The denial created a national debate; Jensen’s advocates persuaded one of the hospitals to reconsider.^3,4 

In 1996, Jensen received the transplant, but she died 18 months later from complications of immunosuppressive therapy. Her surgery was a landmark event; previously, no patient with trisomy 21 or intellectual disability had undergone organ transplantation.

Although attitudes and practices have changed in the past 2 decades, intellectual disability is still considered a relative contraindication to certain organ transplants.⁵

Why is intellectual disability still a contraindication?
Allocation of transplant organs is based primarily on the ethical principle of utilitarianism: ie, a morally good action is one that helps the greatest number of people. “Benefit” might take the form of the number of lives saved or the number of years added to a patient’s life.

There is little consensus on the definition of quality of life, with its debatable ideological standpoint that stands, at times, in contrast to distributive justice. Studies have shown that the long-term outcome for patients with intellectual disability who received a kidney transplant is comparable to the outcome after renal transplant for patients who are not intellectually disabled. In other studies, patients with intellectual disability and their caregivers report improvement in quality of life after transplant.

The goal of successful transplantation is improvement in quality of life and an increase in longevity. Compliance with all aspects of post-transplant treatment is essential—which is why intellectual disability remains a relative contraindication to heart transplantation in the guidelines of the International Society for Heart and Lung Transplantation. The society’s position is based on a theoretical rationale: ie, “concerns about compliance.”

Only 7 cases of successful long-term outcome after cardiac transplantation have been reported in patients with intellectual disability, and these were marked by the presence of the social and cognitive support necessary for post-transplant compliance with treatment.⁵ One of these 7 patients had a lengthy hospitalization 4 years after transplantation because of poor adherence to his medication regimen, following the functional decline of his primary caregiver.

Two-pronged evaluation is needed. Most patients undergoing organ transplantation receive a psychosocial assessment that varies from institution to institution. Intellectual disability can add complexity to the task of assessing candidacy for transplantation, however. In these patients, the availability and adequacy of caregivers is as important a part of decision-making as assessment of the patients themselves—yet studies of the assessment of caregivers are limited. The patient’s caregivers should be present during evaluation so that their knowledge, ability, and willingness to take on post-transplant responsibilities can be assessed. More research is needed on long-term outcomes of successful transplantation in patients with intellectual disability.

CASE CONTINUED Placement on hold
The transplant committee decides to postpone placing Mr. B on the transplant waiting list. Consensus is to revisit the question of placing him on the list at a later date.

What led to this decision?
The committee had several concerns about approving Mr. B for a transplant:

• His history of pulling out the catheter meant that he would require closer postoperative monitoring, because he would likely have drains and a urinary catheter inserted.
• Maintaining adequate oral hydration with a new kidney could be a challenge because Mr. B would not be able to comprehend how dehydration can destroy a new kidney.
• His parents believed that, after transplant, Mr. B would not be dependent on them; they failed to understand that he requires lifelong supervision to ensure compliance with immunosuppressive medications and return for follow-up.

The committee’s decision was aided by the rationale that dialysis is readily available and is a sustainable alternative to transplantation.

Mr. B’s case raises an ethical question
We speculate what the team’s decision about transplantation would have been if Mr. B (1) had a living donor or (2) was being considered for a heart, lung, or liver transplant—for which there is no analogous procedure to dialysis to sustain the patient.

CASE REPORT Evaluation for renal transplant

Mr. B, age 21, who has a diagnosis of autism spectrum disorder and an IQ comparable to that of a 4-year-old, is referred for evaluation of his candidacy for renal transplant.

A few months earlier, Mr. B pulled out his temporary dialysis catheter. Now, he receives hemodialysis through an arteriovenous fistula in the arm, but requires constant supervision during dialysis.

At evaluation, Mr. B is accompanied by his parents and his older sister, who have been providing day-to-day care for him. They appear fully committed to his well-being.

Mr. B does not have a living donor.

Needed: Assessment of adaptive functioning
DSM-5 defines intellectual disability as a disorder with onset during the developmental period. It includes deficits of intellectual and adaptive functioning in conceptual, social, and practical domains.

Regrettably, many authors focus exclusively on intellectual functioning and IQ, classifying patients as having intellectual disability based on intelligence tests alone.^1,2 Adaptive capabilities are insufficiently taken into consideration; there is an urgent need to supplement IQ testing with neuropsychological testing of a patient’s cognitive and adaptive functioning.

Landmark case
In 1995, Sandra Jensen, age 34, with trisomy 21 (Down syndrome) was denied a heart and lung transplant at 2 prominent academic institutions. The denial created a national debate; Jensen’s advocates persuaded one of the hospitals to reconsider.^3,4 

In 1996, Jensen received the transplant, but she died 18 months later from complications of immunosuppressive therapy. Her surgery was a landmark event; previously, no patient with trisomy 21 or intellectual disability had undergone organ transplantation.

Although attitudes and practices have changed in the past 2 decades, intellectual disability is still considered a relative contraindication to certain organ transplants.⁵

Why is intellectual disability still a contraindication?
Allocation of transplant organs is based primarily on the ethical principle of utilitarianism: ie, a morally good action is one that helps the greatest number of people. “Benefit” might take the form of the number of lives saved or the number of years added to a patient’s life.

There is little consensus on the definition of quality of life, with its debatable ideological standpoint that stands, at times, in contrast to distributive justice. Studies have shown that the long-term outcome for patients with intellectual disability who received a kidney transplant is comparable to the outcome after renal transplant for patients who are not intellectually disabled. In other studies, patients with intellectual disability and their caregivers report improvement in quality of life after transplant.

The goal of successful transplantation is improvement in quality of life and an increase in longevity. Compliance with all aspects of post-transplant treatment is essential—which is why intellectual disability remains a relative contraindication to heart transplantation in the guidelines of the International Society for Heart and Lung Transplantation. The society’s position is based on a theoretical rationale: ie, “concerns about compliance.”

Only 7 cases of successful long-term outcome after cardiac transplantation have been reported in patients with intellectual disability, and these were marked by the presence of the social and cognitive support necessary for post-transplant compliance with treatment.⁵ One of these 7 patients had a lengthy hospitalization 4 years after transplantation because of poor adherence to his medication regimen, following the functional decline of his primary caregiver.

Two-pronged evaluation is needed. Most patients undergoing organ transplantation receive a psychosocial assessment that varies from institution to institution. Intellectual disability can add complexity to the task of assessing candidacy for transplantation, however. In these patients, the availability and adequacy of caregivers is as important a part of decision-making as assessment of the patients themselves—yet studies of the assessment of caregivers are limited. The patient’s caregivers should be present during evaluation so that their knowledge, ability, and willingness to take on post-transplant responsibilities can be assessed. More research is needed on long-term outcomes of successful transplantation in patients with intellectual disability.

CASE CONTINUED Placement on hold
The transplant committee decides to postpone placing Mr. B on the transplant waiting list. Consensus is to revisit the question of placing him on the list at a later date.

What led to this decision?
The committee had several concerns about approving Mr. B for a transplant:

• His history of pulling out the catheter meant that he would require closer postoperative monitoring, because he would likely have drains and a urinary catheter inserted.
• Maintaining adequate oral hydration with a new kidney could be a challenge because Mr. B would not be able to comprehend how dehydration can destroy a new kidney.
• His parents believed that, after transplant, Mr. B would not be dependent on them; they failed to understand that he requires lifelong supervision to ensure compliance with immunosuppressive medications and return for follow-up.

The committee’s decision was aided by the rationale that dialysis is readily available and is a sustainable alternative to transplantation.

Mr. B’s case raises an ethical question
We speculate what the team’s decision about transplantation would have been if Mr. B (1) had a living donor or (2) was being considered for a heart, lung, or liver transplant—for which there is no analogous procedure to dialysis to sustain the patient.

Several older physicians have emphasized to me the importance of choosing an excellent disability insurance policy during residency. However, choosing the right policy can be a difficult task. The policy definitions are complicated, and there is a lot of fine print. To understand this confusing topic, start with answers to these 3 questions: What is my most valuable asset? When is the best point in my career to purchase disability insurance? What would I do if I were no longer able to perform the material and substantial duties of my occupation as a dermatologist?

A Resident’s Assets

In the world of disability insurance, your most valuable assets are your education and your ability to earn an income in the future.^1,2 A resident’s ability to earn an income in the future reflects a massive investment of time, cost of education, and postponed accruement of wealth due to time spent in training. Any negative impact on your health (eg, back injury, vision loss, hand injury) can jeopardize these assets. Purchasing disability insurance while still in dermatology residency will protect this investment; it also will ensure that you obtain a policy while you are still healthy.^1,2

Choosing a Policy

Disability insurance comes in 2 main forms: individual or group. Individual insurance may be slightly more expensive but may offer better coverage than group insurance. Group insurance often is offered through a large medical association such as the American Academy of Dermatology. Group insurance may be less expensive but often has more limits to coverage. A definite must-have in a disability insurance policy is one that has guaranteed renewal and is noncancellable.^1-3

Interestingly, women are considered a higher risk for disability, and many insurance policies will charge a higher monthly rate for women than men because women are slightly more likely than men to develop a disability, and women are more likely to develop a disability that prevents them from being able to work.⁴ Some insurance companies do offer a unisex policy, which does not discriminate.

When choosing a policy, you want to carefully read the vendor’s definition of disability. The best definition of the term disability is going to be one that includes phrases such as “unable to perform the material and substantial duties of your [own] occupation . . . even if you are gainfully employed in another occupation.”^1-3,5,6 This definition of disability is the least restrictive and would allow you to receive full benefits even if you are able to work in another capacity or occupation.^1-3,5,6 The benefit period of the policy also is something to choose carefully. It is recommended to choose a benefit period that extends to at least 65 years of age.^1-3,5 It is important to remember that the devil is in the details; for example, some disability insurance policies with more restrictive definitions will not pay you benefits if you are working in another capacity (eg, a physician who develops an injury that prohibits working with patients and then chooses to work in another capacity).

Some policies will only pay benefits if you become totally disabled. Shy away from these more restrictive policies; instead, look for a policy that has a liberal definition of what constitutes disability and allows you the option to add in a future purchase option rider. It is important that your policy includes a future purchase option rider, which means that as your income increases you have the option to purchase an increase in your disability coverage.^1-3,5 Look for a policy that allows you to be insured without penalizing you for preexisting conditions; during residency is one of the few times some policy vendors will do it, as they assume residents are generally young and healthy.^1-3,5,7

Final Thoughts

When you choose your policy, read the details carefully. Finally, remember that other physicians in the community are available as resources; they can be a wealth of information on different policies. There are many websites available to read more on this topic. Often, your training institution will offer a disability policy for the duration of your residency. Many residents choose to purchase their postresidency policies while in their third or fourth year of training. Take the time to choose a good policy now; you will be glad you did.

Several older physicians have emphasized to me the importance of choosing an excellent disability insurance policy during residency. However, choosing the right policy can be a difficult task. The policy definitions are complicated, and there is a lot of fine print. To understand this confusing topic, start with answers to these 3 questions: What is my most valuable asset? When is the best point in my career to purchase disability insurance? What would I do if I were no longer able to perform the material and substantial duties of my occupation as a dermatologist?

A Resident’s Assets

In the world of disability insurance, your most valuable assets are your education and your ability to earn an income in the future.^1,2 A resident’s ability to earn an income in the future reflects a massive investment of time, cost of education, and postponed accruement of wealth due to time spent in training. Any negative impact on your health (eg, back injury, vision loss, hand injury) can jeopardize these assets. Purchasing disability insurance while still in dermatology residency will protect this investment; it also will ensure that you obtain a policy while you are still healthy.^1,2

Choosing a Policy

Disability insurance comes in 2 main forms: individual or group. Individual insurance may be slightly more expensive but may offer better coverage than group insurance. Group insurance often is offered through a large medical association such as the American Academy of Dermatology. Group insurance may be less expensive but often has more limits to coverage. A definite must-have in a disability insurance policy is one that has guaranteed renewal and is noncancellable.^1-3

Interestingly, women are considered a higher risk for disability, and many insurance policies will charge a higher monthly rate for women than men because women are slightly more likely than men to develop a disability, and women are more likely to develop a disability that prevents them from being able to work.⁴ Some insurance companies do offer a unisex policy, which does not discriminate.

When choosing a policy, you want to carefully read the vendor’s definition of disability. The best definition of the term disability is going to be one that includes phrases such as “unable to perform the material and substantial duties of your [own] occupation . . . even if you are gainfully employed in another occupation.”^1-3,5,6 This definition of disability is the least restrictive and would allow you to receive full benefits even if you are able to work in another capacity or occupation.^1-3,5,6 The benefit period of the policy also is something to choose carefully. It is recommended to choose a benefit period that extends to at least 65 years of age.^1-3,5 It is important to remember that the devil is in the details; for example, some disability insurance policies with more restrictive definitions will not pay you benefits if you are working in another capacity (eg, a physician who develops an injury that prohibits working with patients and then chooses to work in another capacity).

Some policies will only pay benefits if you become totally disabled. Shy away from these more restrictive policies; instead, look for a policy that has a liberal definition of what constitutes disability and allows you the option to add in a future purchase option rider. It is important that your policy includes a future purchase option rider, which means that as your income increases you have the option to purchase an increase in your disability coverage.^1-3,5 Look for a policy that allows you to be insured without penalizing you for preexisting conditions; during residency is one of the few times some policy vendors will do it, as they assume residents are generally young and healthy.^1-3,5,7

Final Thoughts

When you choose your policy, read the details carefully. Finally, remember that other physicians in the community are available as resources; they can be a wealth of information on different policies. There are many websites available to read more on this topic. Often, your training institution will offer a disability policy for the duration of your residency. Many residents choose to purchase their postresidency policies while in their third or fourth year of training. Take the time to choose a good policy now; you will be glad you did.

Several older physicians have emphasized to me the importance of choosing an excellent disability insurance policy during residency. However, choosing the right policy can be a difficult task. The policy definitions are complicated, and there is a lot of fine print. To understand this confusing topic, start with answers to these 3 questions: What is my most valuable asset? When is the best point in my career to purchase disability insurance? What would I do if I were no longer able to perform the material and substantial duties of my occupation as a dermatologist?

A Resident’s Assets

In the world of disability insurance, your most valuable assets are your education and your ability to earn an income in the future.^1,2 A resident’s ability to earn an income in the future reflects a massive investment of time, cost of education, and postponed accruement of wealth due to time spent in training. Any negative impact on your health (eg, back injury, vision loss, hand injury) can jeopardize these assets. Purchasing disability insurance while still in dermatology residency will protect this investment; it also will ensure that you obtain a policy while you are still healthy.^1,2

Choosing a Policy

Disability insurance comes in 2 main forms: individual or group. Individual insurance may be slightly more expensive but may offer better coverage than group insurance. Group insurance often is offered through a large medical association such as the American Academy of Dermatology. Group insurance may be less expensive but often has more limits to coverage. A definite must-have in a disability insurance policy is one that has guaranteed renewal and is noncancellable.^1-3

Interestingly, women are considered a higher risk for disability, and many insurance policies will charge a higher monthly rate for women than men because women are slightly more likely than men to develop a disability, and women are more likely to develop a disability that prevents them from being able to work.⁴ Some insurance companies do offer a unisex policy, which does not discriminate.

When choosing a policy, you want to carefully read the vendor’s definition of disability. The best definition of the term disability is going to be one that includes phrases such as “unable to perform the material and substantial duties of your [own] occupation . . . even if you are gainfully employed in another occupation.”^1-3,5,6 This definition of disability is the least restrictive and would allow you to receive full benefits even if you are able to work in another capacity or occupation.^1-3,5,6 The benefit period of the policy also is something to choose carefully. It is recommended to choose a benefit period that extends to at least 65 years of age.^1-3,5 It is important to remember that the devil is in the details; for example, some disability insurance policies with more restrictive definitions will not pay you benefits if you are working in another capacity (eg, a physician who develops an injury that prohibits working with patients and then chooses to work in another capacity).

Some policies will only pay benefits if you become totally disabled. Shy away from these more restrictive policies; instead, look for a policy that has a liberal definition of what constitutes disability and allows you the option to add in a future purchase option rider. It is important that your policy includes a future purchase option rider, which means that as your income increases you have the option to purchase an increase in your disability coverage.^1-3,5 Look for a policy that allows you to be insured without penalizing you for preexisting conditions; during residency is one of the few times some policy vendors will do it, as they assume residents are generally young and healthy.^1-3,5,7

Final Thoughts

When you choose your policy, read the details carefully. Finally, remember that other physicians in the community are available as resources; they can be a wealth of information on different policies. There are many websites available to read more on this topic. Often, your training institution will offer a disability policy for the duration of your residency. Many residents choose to purchase their postresidency policies while in their third or fourth year of training. Take the time to choose a good policy now; you will be glad you did.

On July 9, 2015, the Centers for Medicare and Medicaid Services announced the Comprehensive Care for Joint Replacement model, which aims to improve coordination of the whole episode of care for total hip and knee replacement.¹ At stake is the fact that hip and knee replacements are the most common inpatient procedures among Medicare beneficiaries, costing over $7 billion in 2014¹ and projected to grow to $50 billion by 2030.² Under Medicare’s new initiative, hospitals and physicians are held accountable for the quality and cost of care delivered from the time of surgery through 90 days after discharge. For the first time in the history of our profession, large-scale reimbursement is based on outcomes and value rather than fee-for-service. As a result, a hospital can either earn a reward or be held liable for added expenses related to events such as prolonged hospitalization, readmissions, and complications.

How can we optimize outcomes for total joint arthroplasty (TJA) patients in this era of Medicare (r)evolution? A good outcome starts with good patient selection. Numerous studies have been published on patient-related risk factors for postoperative TJA complications including obesity, congestive heart failure, lung disease, and depression.^3,4 The risks and benefits of TJA should be carefully weighed in high-risk patients and surgery delayed until appropriate medical optimization has been achieved. Following the famous saying, “Good surgeons know how to operate, better surgeons know when to operate, and the best surgeons know when not to operate,” one cannot overemphasize the need for an objective assessment of the likelihood of patient outcome weighed against patient risk factors.

Moderating patient expectation is another crucial component given the changing demographics of our country. Patients seeking TJA today are younger, more obese, and better educated; live longer; and have higher expectations.⁵ Unrealistic expectations can have a profound impact on surgical outcomes, leading to frustration, dissatisfaction, and unnecessary resource utilization. For example, despite alleviating pain and restoring function in a severely degenerative joint, TJA does not necessarily translate to weight loss. There is currently conflicting evidence on this topic,^6-8 and the expectation of weight loss after TJA cannot be supported. There is also a paucity of data regarding return to athletic activity after TJA and the effect of athletic activity on TJA survivorship.⁹ Communication and transparency are needed to moderate unrealistic expectations before surgery, outlining clear and achievable goals.

Clinical pathways for TJA have seen tremendous improvements in the past decade with the advent of multimodal analgesia, rapid recovery programs, use of spinal and regional anesthesia, and evidence-based guidelines for prevention of venous thromboembolic disease. Adequate pain control is critical to recovery. In a prospective, randomized controlled trial, Lamplot and colleagues¹⁰ showed that the use of multimodal analgesia correlated with improved pain scores, decreased narcotic usage, faster functional recovery, and higher patient satisfaction after total knee arthroplasty (TKA). In another study, Quack and colleagues¹¹ performed a systematic review of the literature on fast-track rehabilitation and found that it reduced both inpatient length of stay and costs after TKA. With respect to anesthetic choice, Pugely and colleagues¹² reviewed a national database of 14,052 cases of primary TKA and found that patients with multiple comorbidities were at higher risk of complications after general anesthesia when compared with spinal anesthesia. We should continue to invest in safer and more effective modalities for pain control and functional recovery.

Last but not least, in today’s era of Medicare’s Comprehensive Care for Joint Replacement, the role of low-volume orthopedic surgeons performing TJA deserves special mention. Over the next few years, we could likely see a decline in the role of low-volume surgeons in favor of high-volume surgeons. While most orthopedic surgeons are comfortable doing primary TJA, failed cases and complications are frequently referred to larger centers, which may create frustration among patients owing to fragmentation of care. The economic pressures related to bundled payments could further influence this transition. Given the lack of a widespread, long-standing national joint registry, the incidence of failed TJA performed by low-volume orthopedic surgeons compared with high-volume orthopedic surgeons is unknown. However, multiple studies have shown surgeon volume to be associated with lower rates of complication, mortality, readmission, reoperation, and discharge to postacute facilities.^13-16 As hospitals assume further financial risk, considerable data on physician performance will undoubtedly be gathered and leveraged. Time and data will determine the value of this transition of care.

Today, more than ever, we are challenged to provide efficient, high-quality, patient-centered care. As our nation grapples with reforming a broken health care system, initiatives like the Comprehensive Care for Joint Replacement will continue to emerge in the future. Orthopedic surgeons are the gatekeepers of the system and therefore hold significant responsibility to patients and society. Ensuring good outcomes should be a top priority not just from a financial standpoint, but as a moral obligation. We shall continue to be leaders in the face of challenges, using innovation and integrity to produce the best results and advance our profession.

On July 9, 2015, the Centers for Medicare and Medicaid Services announced the Comprehensive Care for Joint Replacement model, which aims to improve coordination of the whole episode of care for total hip and knee replacement.¹ At stake is the fact that hip and knee replacements are the most common inpatient procedures among Medicare beneficiaries, costing over $7 billion in 2014¹ and projected to grow to $50 billion by 2030.² Under Medicare’s new initiative, hospitals and physicians are held accountable for the quality and cost of care delivered from the time of surgery through 90 days after discharge. For the first time in the history of our profession, large-scale reimbursement is based on outcomes and value rather than fee-for-service. As a result, a hospital can either earn a reward or be held liable for added expenses related to events such as prolonged hospitalization, readmissions, and complications.

How can we optimize outcomes for total joint arthroplasty (TJA) patients in this era of Medicare (r)evolution? A good outcome starts with good patient selection. Numerous studies have been published on patient-related risk factors for postoperative TJA complications including obesity, congestive heart failure, lung disease, and depression.^3,4 The risks and benefits of TJA should be carefully weighed in high-risk patients and surgery delayed until appropriate medical optimization has been achieved. Following the famous saying, “Good surgeons know how to operate, better surgeons know when to operate, and the best surgeons know when not to operate,” one cannot overemphasize the need for an objective assessment of the likelihood of patient outcome weighed against patient risk factors.

Moderating patient expectation is another crucial component given the changing demographics of our country. Patients seeking TJA today are younger, more obese, and better educated; live longer; and have higher expectations.⁵ Unrealistic expectations can have a profound impact on surgical outcomes, leading to frustration, dissatisfaction, and unnecessary resource utilization. For example, despite alleviating pain and restoring function in a severely degenerative joint, TJA does not necessarily translate to weight loss. There is currently conflicting evidence on this topic,^6-8 and the expectation of weight loss after TJA cannot be supported. There is also a paucity of data regarding return to athletic activity after TJA and the effect of athletic activity on TJA survivorship.⁹ Communication and transparency are needed to moderate unrealistic expectations before surgery, outlining clear and achievable goals.

Clinical pathways for TJA have seen tremendous improvements in the past decade with the advent of multimodal analgesia, rapid recovery programs, use of spinal and regional anesthesia, and evidence-based guidelines for prevention of venous thromboembolic disease. Adequate pain control is critical to recovery. In a prospective, randomized controlled trial, Lamplot and colleagues¹⁰ showed that the use of multimodal analgesia correlated with improved pain scores, decreased narcotic usage, faster functional recovery, and higher patient satisfaction after total knee arthroplasty (TKA). In another study, Quack and colleagues¹¹ performed a systematic review of the literature on fast-track rehabilitation and found that it reduced both inpatient length of stay and costs after TKA. With respect to anesthetic choice, Pugely and colleagues¹² reviewed a national database of 14,052 cases of primary TKA and found that patients with multiple comorbidities were at higher risk of complications after general anesthesia when compared with spinal anesthesia. We should continue to invest in safer and more effective modalities for pain control and functional recovery.

Last but not least, in today’s era of Medicare’s Comprehensive Care for Joint Replacement, the role of low-volume orthopedic surgeons performing TJA deserves special mention. Over the next few years, we could likely see a decline in the role of low-volume surgeons in favor of high-volume surgeons. While most orthopedic surgeons are comfortable doing primary TJA, failed cases and complications are frequently referred to larger centers, which may create frustration among patients owing to fragmentation of care. The economic pressures related to bundled payments could further influence this transition. Given the lack of a widespread, long-standing national joint registry, the incidence of failed TJA performed by low-volume orthopedic surgeons compared with high-volume orthopedic surgeons is unknown. However, multiple studies have shown surgeon volume to be associated with lower rates of complication, mortality, readmission, reoperation, and discharge to postacute facilities.^13-16 As hospitals assume further financial risk, considerable data on physician performance will undoubtedly be gathered and leveraged. Time and data will determine the value of this transition of care.

Today, more than ever, we are challenged to provide efficient, high-quality, patient-centered care. As our nation grapples with reforming a broken health care system, initiatives like the Comprehensive Care for Joint Replacement will continue to emerge in the future. Orthopedic surgeons are the gatekeepers of the system and therefore hold significant responsibility to patients and society. Ensuring good outcomes should be a top priority not just from a financial standpoint, but as a moral obligation. We shall continue to be leaders in the face of challenges, using innovation and integrity to produce the best results and advance our profession.

On July 9, 2015, the Centers for Medicare and Medicaid Services announced the Comprehensive Care for Joint Replacement model, which aims to improve coordination of the whole episode of care for total hip and knee replacement.¹ At stake is the fact that hip and knee replacements are the most common inpatient procedures among Medicare beneficiaries, costing over $7 billion in 2014¹ and projected to grow to $50 billion by 2030.² Under Medicare’s new initiative, hospitals and physicians are held accountable for the quality and cost of care delivered from the time of surgery through 90 days after discharge. For the first time in the history of our profession, large-scale reimbursement is based on outcomes and value rather than fee-for-service. As a result, a hospital can either earn a reward or be held liable for added expenses related to events such as prolonged hospitalization, readmissions, and complications.

How can we optimize outcomes for total joint arthroplasty (TJA) patients in this era of Medicare (r)evolution? A good outcome starts with good patient selection. Numerous studies have been published on patient-related risk factors for postoperative TJA complications including obesity, congestive heart failure, lung disease, and depression.^3,4 The risks and benefits of TJA should be carefully weighed in high-risk patients and surgery delayed until appropriate medical optimization has been achieved. Following the famous saying, “Good surgeons know how to operate, better surgeons know when to operate, and the best surgeons know when not to operate,” one cannot overemphasize the need for an objective assessment of the likelihood of patient outcome weighed against patient risk factors.

Moderating patient expectation is another crucial component given the changing demographics of our country. Patients seeking TJA today are younger, more obese, and better educated; live longer; and have higher expectations.⁵ Unrealistic expectations can have a profound impact on surgical outcomes, leading to frustration, dissatisfaction, and unnecessary resource utilization. For example, despite alleviating pain and restoring function in a severely degenerative joint, TJA does not necessarily translate to weight loss. There is currently conflicting evidence on this topic,^6-8 and the expectation of weight loss after TJA cannot be supported. There is also a paucity of data regarding return to athletic activity after TJA and the effect of athletic activity on TJA survivorship.⁹ Communication and transparency are needed to moderate unrealistic expectations before surgery, outlining clear and achievable goals.

Clinical pathways for TJA have seen tremendous improvements in the past decade with the advent of multimodal analgesia, rapid recovery programs, use of spinal and regional anesthesia, and evidence-based guidelines for prevention of venous thromboembolic disease. Adequate pain control is critical to recovery. In a prospective, randomized controlled trial, Lamplot and colleagues¹⁰ showed that the use of multimodal analgesia correlated with improved pain scores, decreased narcotic usage, faster functional recovery, and higher patient satisfaction after total knee arthroplasty (TKA). In another study, Quack and colleagues¹¹ performed a systematic review of the literature on fast-track rehabilitation and found that it reduced both inpatient length of stay and costs after TKA. With respect to anesthetic choice, Pugely and colleagues¹² reviewed a national database of 14,052 cases of primary TKA and found that patients with multiple comorbidities were at higher risk of complications after general anesthesia when compared with spinal anesthesia. We should continue to invest in safer and more effective modalities for pain control and functional recovery.

Last but not least, in today’s era of Medicare’s Comprehensive Care for Joint Replacement, the role of low-volume orthopedic surgeons performing TJA deserves special mention. Over the next few years, we could likely see a decline in the role of low-volume surgeons in favor of high-volume surgeons. While most orthopedic surgeons are comfortable doing primary TJA, failed cases and complications are frequently referred to larger centers, which may create frustration among patients owing to fragmentation of care. The economic pressures related to bundled payments could further influence this transition. Given the lack of a widespread, long-standing national joint registry, the incidence of failed TJA performed by low-volume orthopedic surgeons compared with high-volume orthopedic surgeons is unknown. However, multiple studies have shown surgeon volume to be associated with lower rates of complication, mortality, readmission, reoperation, and discharge to postacute facilities.^13-16 As hospitals assume further financial risk, considerable data on physician performance will undoubtedly be gathered and leveraged. Time and data will determine the value of this transition of care.

Today, more than ever, we are challenged to provide efficient, high-quality, patient-centered care. As our nation grapples with reforming a broken health care system, initiatives like the Comprehensive Care for Joint Replacement will continue to emerge in the future. Orthopedic surgeons are the gatekeepers of the system and therefore hold significant responsibility to patients and society. Ensuring good outcomes should be a top priority not just from a financial standpoint, but as a moral obligation. We shall continue to be leaders in the face of challenges, using innovation and integrity to produce the best results and advance our profession.

In recent years, resistance to antimicrobial drugs has become increasingly widespread, resulting in a health threat of epidemic proportions. The long list of drug-resistant bacteria continues to expand at an accelerated pace. What does this mean in the dermatology world? We are not the only problem but are certainly part of the problem, representing 5% of all antibiotic prescriptions annually even though we represent only 1% of all physicians in the United States. These prescriptions certainly do not just include skin and soft tissue functions, as a survey-based study by Chouake et al (J Drugs Dermatol. 2014;13:119-124.) showed that dermatologists are overusing antibiotics in the treatment of simple skin abscesses such as acne vulgaris, one of the most common inflammatory skin diseases.

Although the inappropriate utilization of antibiotics for acne has been a subject of great discourse for years, it recently reentered the limelight in a study by Nagler et al published online in October 2015 in the Journal of the American Academy of Dermatology. They showed that patients who ultimately were treated with isotretinoin had been receiving antibiotics for months without any sign of therapeutic life or course end in sight. This retrospective chart review evaluated the duration of systemic antibiotic use prior to starting isotretinoin in 137 patients with inflammatory/nodulocystic acne. Antibiotic use continued for a mean of 331.3 days (median, 238 days). Duration of antibiotic use was divided into categories: 3 months or less (15.3%), 6 months or more (64.2%), or 1 year or more (33.6%).

Let’s take a broad look at antimicrobial resistance. Bacterial drug resistance has numerous negative effects on medicine and society. Drug-resistant bacterial infections result in higher doses of drugs, the addition of treatments with higher toxicity, longer hospital stays, and increased mortality. In the United States, infections due to antibiotic-resistant bacteria add $20 billion to total health care costs plus $35 billion in costs to society.

Unfortunately, it is relatively easy for bacterium to develop drug resistance through 3 simple steps: acquisition by microbes of resistance genes, expression of those resistance genes, and selection for pathogens expressing those resistance genes. The selective pressure in favor of resistance occurs whenever microbes are exposed to a drug but not eradicated, either by the killing effects of the drug itself or by inhibitory effects of the drug followed by killing by the host’s immune system. In any setting that creates this selective pressure in favor of drug resistance, such as poor patient compliance (ie, infrequent dosing, taking an antibiotic for too long as we see with the use of antibiotics for the treatment of inflammatory skin diseases such as acne), the likelihood of that resistance actually developing is increased. In addition, drugs that inhibit but do not kill microbes are more likely to allow some microbial cells to live and therefore develop resistance when exposed to a drug, which accounts for the majority of antibiotics in our armament. Lastly, abuse of broad-spectrum antibiotics has further spurred the emergence of many antibiotic-resistant strains. For instance, Pseudomonas aeruginosa is one of many evolving multidrug-resistant microorganisms that have been collectively coined the “ESKAPE” pathogens (Enterococcus faecalis, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, P aeruginosa, Enterobacter species) to emphasize the fact that they “escape” the effects of many antibacterial agents.

All of the above does not take into account the environmental factors that play a role in this resistance. The close quarters, mass/public transportation, and stressful pace of life of urban living not only bring these organisms together to share resistance genes but also increase our susceptibility.

What’s the issue?

We can all do our part in the fight against microbial resistance and join the antimicrobial stewardship. Here are a couple tips for dermatologists:

1. Stop using over-the-counter antibiotic ointment for every biopsy or minor procedure, which is one of the recommendations of the American Academy of Dermatology based on the ABIM Foundation’s Choosing Wisely campaign.
2. Oral and topical antibiotics for inflammatory skin diseases such as acne, rosacea, and hidradenitis suppurativa should only be used temporarily or at subantimicrobial dosing. Always combine a benzoyl peroxide–containing wash with a topical or oral antibiotic to hit the bacteria with multiple mechanisms of antibacterial activity to limit resistance. Don’t use benzoyl peroxide stronger than 2.5% for the face; make sure to wash it off completely to avoid staining your towels, sheets, and clothing.

We can all play our part in the fight against antimicrobial resistance. How do you fight the resistance?

We want to know your views! Tell us what you think.

In recent years, resistance to antimicrobial drugs has become increasingly widespread, resulting in a health threat of epidemic proportions. The long list of drug-resistant bacteria continues to expand at an accelerated pace. What does this mean in the dermatology world? We are not the only problem but are certainly part of the problem, representing 5% of all antibiotic prescriptions annually even though we represent only 1% of all physicians in the United States. These prescriptions certainly do not just include skin and soft tissue functions, as a survey-based study by Chouake et al (J Drugs Dermatol. 2014;13:119-124.) showed that dermatologists are overusing antibiotics in the treatment of simple skin abscesses such as acne vulgaris, one of the most common inflammatory skin diseases.

Although the inappropriate utilization of antibiotics for acne has been a subject of great discourse for years, it recently reentered the limelight in a study by Nagler et al published online in October 2015 in the Journal of the American Academy of Dermatology. They showed that patients who ultimately were treated with isotretinoin had been receiving antibiotics for months without any sign of therapeutic life or course end in sight. This retrospective chart review evaluated the duration of systemic antibiotic use prior to starting isotretinoin in 137 patients with inflammatory/nodulocystic acne. Antibiotic use continued for a mean of 331.3 days (median, 238 days). Duration of antibiotic use was divided into categories: 3 months or less (15.3%), 6 months or more (64.2%), or 1 year or more (33.6%).

Let’s take a broad look at antimicrobial resistance. Bacterial drug resistance has numerous negative effects on medicine and society. Drug-resistant bacterial infections result in higher doses of drugs, the addition of treatments with higher toxicity, longer hospital stays, and increased mortality. In the United States, infections due to antibiotic-resistant bacteria add $20 billion to total health care costs plus $35 billion in costs to society.

Unfortunately, it is relatively easy for bacterium to develop drug resistance through 3 simple steps: acquisition by microbes of resistance genes, expression of those resistance genes, and selection for pathogens expressing those resistance genes. The selective pressure in favor of resistance occurs whenever microbes are exposed to a drug but not eradicated, either by the killing effects of the drug itself or by inhibitory effects of the drug followed by killing by the host’s immune system. In any setting that creates this selective pressure in favor of drug resistance, such as poor patient compliance (ie, infrequent dosing, taking an antibiotic for too long as we see with the use of antibiotics for the treatment of inflammatory skin diseases such as acne), the likelihood of that resistance actually developing is increased. In addition, drugs that inhibit but do not kill microbes are more likely to allow some microbial cells to live and therefore develop resistance when exposed to a drug, which accounts for the majority of antibiotics in our armament. Lastly, abuse of broad-spectrum antibiotics has further spurred the emergence of many antibiotic-resistant strains. For instance, Pseudomonas aeruginosa is one of many evolving multidrug-resistant microorganisms that have been collectively coined the “ESKAPE” pathogens (Enterococcus faecalis, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, P aeruginosa, Enterobacter species) to emphasize the fact that they “escape” the effects of many antibacterial agents.

All of the above does not take into account the environmental factors that play a role in this resistance. The close quarters, mass/public transportation, and stressful pace of life of urban living not only bring these organisms together to share resistance genes but also increase our susceptibility.

What’s the issue?

We can all do our part in the fight against microbial resistance and join the antimicrobial stewardship. Here are a couple tips for dermatologists:

1. Stop using over-the-counter antibiotic ointment for every biopsy or minor procedure, which is one of the recommendations of the American Academy of Dermatology based on the ABIM Foundation’s Choosing Wisely campaign.
2. Oral and topical antibiotics for inflammatory skin diseases such as acne, rosacea, and hidradenitis suppurativa should only be used temporarily or at subantimicrobial dosing. Always combine a benzoyl peroxide–containing wash with a topical or oral antibiotic to hit the bacteria with multiple mechanisms of antibacterial activity to limit resistance. Don’t use benzoyl peroxide stronger than 2.5% for the face; make sure to wash it off completely to avoid staining your towels, sheets, and clothing.

We can all play our part in the fight against antimicrobial resistance. How do you fight the resistance?

We want to know your views! Tell us what you think.

In recent years, resistance to antimicrobial drugs has become increasingly widespread, resulting in a health threat of epidemic proportions. The long list of drug-resistant bacteria continues to expand at an accelerated pace. What does this mean in the dermatology world? We are not the only problem but are certainly part of the problem, representing 5% of all antibiotic prescriptions annually even though we represent only 1% of all physicians in the United States. These prescriptions certainly do not just include skin and soft tissue functions, as a survey-based study by Chouake et al (J Drugs Dermatol. 2014;13:119-124.) showed that dermatologists are overusing antibiotics in the treatment of simple skin abscesses such as acne vulgaris, one of the most common inflammatory skin diseases.

Although the inappropriate utilization of antibiotics for acne has been a subject of great discourse for years, it recently reentered the limelight in a study by Nagler et al published online in October 2015 in the Journal of the American Academy of Dermatology. They showed that patients who ultimately were treated with isotretinoin had been receiving antibiotics for months without any sign of therapeutic life or course end in sight. This retrospective chart review evaluated the duration of systemic antibiotic use prior to starting isotretinoin in 137 patients with inflammatory/nodulocystic acne. Antibiotic use continued for a mean of 331.3 days (median, 238 days). Duration of antibiotic use was divided into categories: 3 months or less (15.3%), 6 months or more (64.2%), or 1 year or more (33.6%).

Let’s take a broad look at antimicrobial resistance. Bacterial drug resistance has numerous negative effects on medicine and society. Drug-resistant bacterial infections result in higher doses of drugs, the addition of treatments with higher toxicity, longer hospital stays, and increased mortality. In the United States, infections due to antibiotic-resistant bacteria add $20 billion to total health care costs plus $35 billion in costs to society.

Unfortunately, it is relatively easy for bacterium to develop drug resistance through 3 simple steps: acquisition by microbes of resistance genes, expression of those resistance genes, and selection for pathogens expressing those resistance genes. The selective pressure in favor of resistance occurs whenever microbes are exposed to a drug but not eradicated, either by the killing effects of the drug itself or by inhibitory effects of the drug followed by killing by the host’s immune system. In any setting that creates this selective pressure in favor of drug resistance, such as poor patient compliance (ie, infrequent dosing, taking an antibiotic for too long as we see with the use of antibiotics for the treatment of inflammatory skin diseases such as acne), the likelihood of that resistance actually developing is increased. In addition, drugs that inhibit but do not kill microbes are more likely to allow some microbial cells to live and therefore develop resistance when exposed to a drug, which accounts for the majority of antibiotics in our armament. Lastly, abuse of broad-spectrum antibiotics has further spurred the emergence of many antibiotic-resistant strains. For instance, Pseudomonas aeruginosa is one of many evolving multidrug-resistant microorganisms that have been collectively coined the “ESKAPE” pathogens (Enterococcus faecalis, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, P aeruginosa, Enterobacter species) to emphasize the fact that they “escape” the effects of many antibacterial agents.

All of the above does not take into account the environmental factors that play a role in this resistance. The close quarters, mass/public transportation, and stressful pace of life of urban living not only bring these organisms together to share resistance genes but also increase our susceptibility.

What’s the issue?

We can all do our part in the fight against microbial resistance and join the antimicrobial stewardship. Here are a couple tips for dermatologists:

1. Stop using over-the-counter antibiotic ointment for every biopsy or minor procedure, which is one of the recommendations of the American Academy of Dermatology based on the ABIM Foundation’s Choosing Wisely campaign.
2. Oral and topical antibiotics for inflammatory skin diseases such as acne, rosacea, and hidradenitis suppurativa should only be used temporarily or at subantimicrobial dosing. Always combine a benzoyl peroxide–containing wash with a topical or oral antibiotic to hit the bacteria with multiple mechanisms of antibacterial activity to limit resistance. Don’t use benzoyl peroxide stronger than 2.5% for the face; make sure to wash it off completely to avoid staining your towels, sheets, and clothing.

We can all play our part in the fight against antimicrobial resistance. How do you fight the resistance?

We want to know your views! Tell us what you think.