Residency Roundup

As one of the most competitive specialties in medicine, dermatology presents unique challenges for residency applicants, especially following the shift in United States Medical Licensing Examination (USMLE) Step 1 scoring to a pass/fail format.^1,2 Historically, USMLE Step 1 served as a major screening metric for residency programs, with 90% of program directors in 2020 using USMLE Step 1 scores as a primary factor when deciding whether to invite applicants for interviews.¹ However, the recent transition to pass/fail has made it much harder for program directors to objectively compare applicants, particularly in dermatology. In a 2020 survey, Patrinely Jr et al² found that 77.2% of dermatology program directors agreed that this change would make it more difficult to assess candidates objectively. Consequently, research productivity has taken on greater importance as programs seek new ways to distinguish top applicants.^1,2

In response to this increased emphasis on research, dermatology applicants have substantially boosted their scholarly output over the past several years. The 2022 and 2024 results from the National Residency Matching Program’s Charting Outcomes survey demonstrated a steady rise in research metrics among applicants across various specialties, with dermatology showing one of the largest increases.^3,4 For instance, the average number of abstracts, presentations, and publications for matched allopathic dermatology applicants was 5.7 in 2007.⁵ This average increased to 20.9 in 2022³ and to 27.7 in 2024,⁴ marking an astonishing 485% increase in 17 years. Interestingly, unmatched dermatology applicants had an average of 19.0 research products in 2024, which was similar to the average of successfully matched applicants just 2 years earlier.^3,4

Engaging in research offers benefits beyond building a strong residency application. Specifically, it enhances critical thinking skills and provides hands-on experience in scientific inquiry.⁶ It allows students to explore dermatology topics of interest and address existing knowledge gaps within the specialty.⁶ Additionally, it creates opportunities to build meaningful relationships with experienced dermatologists who can guide and support students throughout their careers.⁷ Despite these benefits, the pursuit of research may be landscaped with obstacles, and the fervent race to obtain high research outputs may overshadow developmental advantages.⁸ These challenges and demands also could contribute to inequities in the residency selection process, particularly if barriers are influenced by socioeconomic and demographic disparities. As dermatology already ranks as the second least diverse specialty in medicine,⁹ research requirements that disproportionately disadvantage certain demographic groups risk further widening these concerning representation gaps rather than creating opportunities to address them.

Given these trends in research requirements and their potential impact on applicant success, understanding specific barriers to research engagement is essential for creating equitable opportunities in dermatology. In this study, we aimed to identify barriers to research engagement among dermatology applicants, analyze their relationship with demographic factors, assess their impact on specialty choice and research productivity, and provide actionable solutions to address these obstacles.

Methods

A cross-sectional survey was conducted targeting medical students applying to dermatology residency programs in the United States in the 2025 or 2026 match cycles as well as residents who applied to dermatology residency in the 2021 to 2024 match cycles. The 23-item survey was developed by adapting questions from several validated studies examining research barriers and experiences in medical education.^6,7,10,11 Specifically, the survey included questions on demographics and background; research productivity; general research barriers; conference participation accessibility; mentorship access; and quality, career impact, and support needs. Socioeconomic background was measured via a single self-reported item asking participants to select the income class that best reflected their background growing up (low-income, lower-middle, upper-middle, or high-income); no income ranges were provided.

The survey was distributed electronically via Qualtrics between November 11, 2024, and December 30, 2024, through listserves of the Dermatology Interest Group Association (sent directly to medical students) and the Association of Professors of Dermatology (forwarded to residents by program directors). There was no way to determine the number of dermatology applicants and residents reached through either listserve. The surveys were reviewed and approved by the University of Alabama at Birmingham institutional review board (IRB-300013671).

Statistical analyses were conducted using RStudio (Posit, PBC; version 2024.12.0+467). Descriptive statistics characterized participant demographics and quantified barrier scores using frequencies and proportions. We performed regression analyses to examine relationships between demographic factors and barriers using linear regression; the relationship between barriers and research productivity correlation; and the prediction of specialty change consideration using logistic regression. For all analyses, barrier scores were rated on a scale of 0 to 3 (0=not a barrier, 1=minor barrier, 2=moderate barrier, 3=major barrier); R² values were reported to indicate strength of associations, and statistical significance was set at P<.05.

Results

Participant Demographics—A total of 136 participants completed the survey. Among the respondents, 12% identified as from a background of low-income class, 28% lower-middle class, 49% upper-middle class, and 11% high-income class. Additionally, 27% of respondents identified as underrepresented in medicine (URiM). Regarding debt levels (or expected debt levels) upon graduation from medical school, 32% reported no debt, 9% reported $1000 to $49,000 in debt, 5% reported $50,000 to $99,000 in debt, 15% reported $100,000 to $199,000 in debt, 22% reported $200,000 to $299,000 in debt, and 17% reported $300,000 in debt or higher. The majority of respondents (95%) were MD candidates, and the remaining 5% were DO candidates; additionally, 5% were participants in an MD/PhD program (eTable 1).

Respondents represented various stages of training: 13.2% and 16.2% were third- and fourth-year medical students, respectively, while 6.0%, 20.1%, 18.4%, and 22.8% were postgraduate year (PGY) 1, PGY-2, PGY-3, and PGY-4, respectively. A few respondents (2.9%) were participating in a research year or reapplying to dermatology residency (eTable 2).

Research Barriers and Productivity—Respondents were presented with a list of potential barriers and asked to rate each as not a barrier, a minor barrier, a moderate barrier, or a major barrier. The most common barriers (ie, those with >50% of respondents rating them as a moderate or major) included lack of time, limited access to research opportunities, not knowing how to begin research, and lack of mentorship or support. Lack of time and not knowing where to begin research were reported most frequently as major barriers, with 32% of participants identifying them as such. In contrast, barriers such as financial costs and personal obligations were less frequently rated as major barriers (10% and 4%, respectively), although they still were identified as obstacles by many respondents. Interestingly, most respondents (58%) indicated that institutional limitations were not a barrier, but a separate and sizeable proportion (25%) of respondents considered it to be a major barrier (eFigure 1).

The distributions for all research metrics were right-skewed. The total range was 0 to 45 (median, 6) for number of publications (excluding abstracts), 0 to 33 (median, 2) for published abstracts, 0 to 40 (median, 5) for poster publications, and 0 to 20 (median, 2) for oral presentations (eTable 3).

Regression Analysis—Linear regression analysis identified significant relationships between demographic variables (socioeconomic status [SES], URiM status, and debt level) and individual research barriers. The heatmap in eFigure 2 illustrates the strength of these relationships. Higher SES was predictive of lower reported financial barriers (R²=.2317; P<.0001) and lower reported institutional limitations (R²=.0884; P=.0006). A URiM status predicted higher reported financial barriers (R²=.1097; P<.0001) and institutional limitations (R²=.04537; P=.013). Also, higher debt level predicted increased financial barriers (R²=.2099; P<.0001), institutional limitations (R²=.1258; P<.0001), and lack of mentorship (R²=.06553; P=.003).

Next, the data were evaluated for correlative relationships between individual research barriers and research productivity metrics including number of publications, published abstracts and presentations (oral and poster) and total research output. While correlations were weak or nonsignificant between barriers and most research productivity metrics (published abstracts, oral and poster presentations, and total research output), the number of publications was significantly correlated with several research barriers, including limited access to research opportunities (P=.002), not knowing how to begin research (P=.025), lack of mentorship or support (P=.011), and institutional limitations (P=.042). Higher ratings for limited access to research opportunities, not knowing where to begin research, lack of mentorship or support, and institutional limitations all were negatively correlated with total number of publications (R²=−.27, –.19, −.22, and –.18, respectively)(eFigure 3).

Logistic regression analysis examined the impact of research barriers on the likelihood of specialty change consideration. The results, presented in a forest plot, include odds ratios (ORs) and their corresponding 95% CIs and P values. Lack of time (P=.001) and not knowing where to begin research (P<.001) were the strongest predictors of specialty change consideration (OR, 6.3 and 4.7, ­respectively). Financial cost (P=.043), limited access to research opportunities (P=.006), and lack of mentorship or support (P=.001) also were significant predictors of specialty change consideration (OR, 2.2, 3.1, and 3.5, respectively). Institutional limitations and personal obligations did not predict specialty change consideration (eTable 4 and eFigure 4).

Mitigation Strategies—Mitigation strategies were ranked by respondents based on their perceived importance on a scale of 1 to 7 (1=most important, 7=least important)(eFigure 5). Respondents considered access to engaged mentors to be the most important mitigation strategy by far, with 95% ranking it in the top 3 (47% of respondents ranked it as the top most important mitigation strategy). Financial assistance was the mitigation strategy with the second highest number of respondents (28%) ranking it as the top strategy. Flexible scheduling during rotations, research training programs or discussions, and peer networking and research collaboration opportunities also were considered by respondents to be important mitigation strategies. Time management support/resources frequently was viewed as the least important mitigation strategy, with 38% of respondents ranking it last.

Comment

Our study revealed notable disparities in research barriers among dermatology applicants, with several demonstrating consistent patterns of association with SES, URiM status, and debt burden. Furthermore, the strong relationship between these barriers and decreased research productivity and specialty change consideration suggests that capable candidates may be deterred from pursuing dermatology due to surmountable obstacles rather than lack of interest or ability.

Impact of Demographic Factors on Research Barriers—All 7 general research barriers surveyed were correlated with distinct demographic predictors. Regression analyses indicated that the barrier of financial cost was significantly predicted by lower SES (R²=.2317; P<.001), URiM status (R²=.1097; P<.001), and higher debt levels (R²=.2099; P<.001)(eFigure 2). These findings are particularly concerning given the trend of dermatology applicants pursuing 1-year research fellowships, many of which are unpaid.¹² In fact, Jacobson et al¹¹ found that 71.7% (43/60) of dermatology applicants who pursued a year-long research fellowship experienced financial strain during their fellowship, with many requiring additional loans or drawing from personal savings despite already carrying substantial medical school debt of $200,000 or more. Our findings showcase how financial barriers to research disproportionately affect students from lower socioeconomic backgrounds, those who identify as URiM, and those with higher debt, creating systemic inequities in research access at a time when research productivity is increasingly vital for matching into dermatology. To address these financial barriers, institutions may consider establishing more funded research fellowships or expanding grant programs targeting students from economically disadvantaged and/or underrepresented backgrounds.

Institutional limitations (eg, the absence of a dermatology department) also was a notable barrier that was significantly predicted by lower SES (R²=.0884; P<.001) and URiM status (R²=.04537; P=.013)(eFigure 2). Students at institutions lacking dermatology programs face restricted access to mentorship and research opportunities,¹³ with our results demonstrating that these barriers disproportionately affect students from underresourced and minority groups. These limitations compound disparities in building competitive residency applications.¹⁴ The Women’s Dermatologic Society (WDS) has developed a model for addressing these institutional barriers through its summer research fellowship program for medical students who identify as URiM. By pairing students with WDS mentors who guide them through summer research projects, this initiative addresses access and mentorship gaps for students lacking dermatology departments at their home institution.¹⁵ The WDS program serves as a model for other organizations to adopt and expand, with particular attention to including students who identify as URiM as well as those from lower socioeconomic backgrounds.

Our results identified time constraints and lack of experience as notable research barriers. Higher debt levels significantly predicted both lack of time (R²=.03915; P=.021) and not knowing how to begin research (R²=.0572; P=.005)(eFigure 2). These statistical relationships may be explained by students with higher debt levels needing to prioritize paid work over unpaid research opportunities, limiting their engagement in research due to the scarcity of funded positions.¹² The data further revealed that personal obligations, particularly family care responsibilities, were significantly predicted by both lower SES (R²=.0539; P=.008) and higher debt level (R²=.03237; P=.036)(eFigure 2). These findings demonstrate how students managing academic demands alongside financial and familial responsibilities may face compounded barriers to research engagement. To address these disparities, medical schools may consider implementing protected research time within their curricula; for example, the Emory University School of Medicine (Atlanta, Georgia) has implemented a Discovery Phase program that provides students with 5 months of protected faculty-mentored research time away from academic demands between their third and fourth years of medical school.¹⁶ Integrating similarly structured research periods across medical school curricula could help ensure equitable research opportunities for all students pursuing competitive specialties such as dermatology.⁸

Access to mentorship is a critical determinant of research engagement and productivity, as mentors provide valuable guidance on navigating research processes and professional development.¹⁷ Our analysis revealed that lack of mentorship was predicted by both lower SES (R²=.039; P=.023) and higher debt level (R²=.06553; P=.003)(eFigure 2). Several organizations have developed programs to address these mentorship gaps. The Skin of Color Society pairs medical students with skin of color experts while advancing its mission of increasing diversity in dermatology.¹⁸ Similarly, the American Academy of Dermatology founded a diversity mentorship program that connects students who identify as URiM with dermatologist mentors for summer research experiences.¹⁹ Notably, the Skin of Color Society’s program allows residents to serve as mentors for medical students. Involving residents and community dermatologists as potential dermatology mentors for medical students not only distributes mentorship demands more sustainably but also increases overall access to dermatology mentors. Our findings indicate that similar programs could be expanded to include more residents and community dermatologists as mentors and to target students from disadvantaged backgrounds, those facing financial constraints, and students who identify as URiM. 

Impact of Research Barriers on Career Trajectories—Among survey participants, 35% reported considering changing their specialty choice due to research-related barriers. This substantial percentage likely stems from the escalating pressure to achieve increasingly high research output amidst a lack of sufficient support, time, or tools, as our results suggest. The specific barriers that most notably predicted specialty change consideration were lack of time and not knowing how to begin research (P=.001 and P<.001, respectively). Remarkably, our findings revealed that respondents who rated these as moderate or major barriers were 6.3 and 4.7 times more likely to consider changing their specialty choice, respectively. Respondents reporting financial cost (P=.043), limited access to research opportunities (P=.006), and lack of mentorship or support (P=.001) as at least moderate barriers also were 2.2 to 3.5 times more likely to consider a specialty change (eTable 4 and eFigure 4). Additionally, barriers such as limited access to research opportunities (R²=−.27; P=.002), lack of mentorship (R²=−.22; P=.011), not knowing how to begin research (R²=−.19; P=.025), and institutional limitations (R²=−.18; P=.042) all were associated with lower publication output according to our data (eFigure 3). These findings are especially concerning given current match statistics, where the trajectory of research productivity required for a successful dermatology match continues to rise sharply.^3,4

Alarmingly, many of the barriers we identified—linked to both reduced research output and specialty change consideration—are associated with several demographic factors. Higher debt levels predicted greater likelihood of experiencing lack of time, insufficient mentorship, and uncertainty about initiating research, while lower SES was associated with lack of mentorship. These relationships suggest that structural barriers, rather than lack of interest or ability, may create cumulative disadvantages that deter capable candidates from pursuing dermatology or impact their success in the application process.

One potential solution to address the disproportionate emphasis on research quantity would be implementing caps on reportable research products in residency applications (eg, limiting applications to a certain number of publications, abstracts, and presentations). This change could shift applicant focus toward substantive scientific contributions rather than rapid output accumulation.⁸ The need for such caps was evident in our dataset, which revealed a stark contrast: some respondents reported 30 to 40 publications, while MD/PhD respondents—who dedicate 3 to 5 years to performing quality research—averaged only 7.4 publications. Implementing a research output ceiling could help alleviate barriers for applicants facing institutional and demographic disadvantages while simultaneously boosting the scientific rigor of dermatology research.⁸

Mitigation Strategies From Applicant Feedback—Our findings emphasize the multifaceted relationship between structural barriers and demographics in dermatology research engagement. While our statistical interpretations have outlined several potential interventions, the applicants’ perspectives on mitigation strategies offer qualitative insight. Although participants did not consistently mark financial cost and lack of mentorship as major barriers (eFigure 1), financial assistance and access to engaged mentors were among the highest-ranked mitigation strategies (eFigure 5), suggesting these resources may be fundamental to overcoming multiple structural challenges. To address these needs comprehensively, we propose a multilevel approach: at the institutional level, dermatology interest groups could establish centralized databases of research opportunities, mentorship programs, and funding sources. At the national level, dermatology organizations could consider expanding grant programs, developing virtual mentorship networks, and creating opportunities for external students through remote research projects or short-term research rotations. These interventions, informed by both our statistical analyses and applicant feedback, could help create more equitable access to research opportunities in dermatology.

Limitations

A major limitation of this study was that potential dermatology candidates who were deterred by barriers and later decided on a different specialty would not be captured in our data. As these candidates may have faced substantial barriers that caused them to choose a different path, their absence from the current data may indicate that the reported results underpredict the effect size of the true population. Another limitation is the absence of a control group, such as applicants to less competitive specialties, which would provide valuable context for whether the barriers identified are unique to dermatology.

Conclusion

Our study provides compelling evidence that research barriers in dermatology residency applications intersect with demographic factors to influence research engagement and career trajectories. Our findings suggest that without targeted intervention, increasing emphasis on research productivity may exacerbate existing disparities in dermatology. Moving forward, a coordinated effort among institutions, dermatology associations, and dermatology residency programs will be fundamental to ensure that research requirements enhance rather than impede the development of a diverse, qualified dermatology workforce.

As one of the most competitive specialties in medicine, dermatology presents unique challenges for residency applicants, especially following the shift in United States Medical Licensing Examination (USMLE) Step 1 scoring to a pass/fail format.^1,2 Historically, USMLE Step 1 served as a major screening metric for residency programs, with 90% of program directors in 2020 using USMLE Step 1 scores as a primary factor when deciding whether to invite applicants for interviews.¹ However, the recent transition to pass/fail has made it much harder for program directors to objectively compare applicants, particularly in dermatology. In a 2020 survey, Patrinely Jr et al² found that 77.2% of dermatology program directors agreed that this change would make it more difficult to assess candidates objectively. Consequently, research productivity has taken on greater importance as programs seek new ways to distinguish top applicants.^1,2

In response to this increased emphasis on research, dermatology applicants have substantially boosted their scholarly output over the past several years. The 2022 and 2024 results from the National Residency Matching Program’s Charting Outcomes survey demonstrated a steady rise in research metrics among applicants across various specialties, with dermatology showing one of the largest increases.^3,4 For instance, the average number of abstracts, presentations, and publications for matched allopathic dermatology applicants was 5.7 in 2007.⁵ This average increased to 20.9 in 2022³ and to 27.7 in 2024,⁴ marking an astonishing 485% increase in 17 years. Interestingly, unmatched dermatology applicants had an average of 19.0 research products in 2024, which was similar to the average of successfully matched applicants just 2 years earlier.^3,4

Engaging in research offers benefits beyond building a strong residency application. Specifically, it enhances critical thinking skills and provides hands-on experience in scientific inquiry.⁶ It allows students to explore dermatology topics of interest and address existing knowledge gaps within the specialty.⁶ Additionally, it creates opportunities to build meaningful relationships with experienced dermatologists who can guide and support students throughout their careers.⁷ Despite these benefits, the pursuit of research may be landscaped with obstacles, and the fervent race to obtain high research outputs may overshadow developmental advantages.⁸ These challenges and demands also could contribute to inequities in the residency selection process, particularly if barriers are influenced by socioeconomic and demographic disparities. As dermatology already ranks as the second least diverse specialty in medicine,⁹ research requirements that disproportionately disadvantage certain demographic groups risk further widening these concerning representation gaps rather than creating opportunities to address them.

Given these trends in research requirements and their potential impact on applicant success, understanding specific barriers to research engagement is essential for creating equitable opportunities in dermatology. In this study, we aimed to identify barriers to research engagement among dermatology applicants, analyze their relationship with demographic factors, assess their impact on specialty choice and research productivity, and provide actionable solutions to address these obstacles.

Methods

A cross-sectional survey was conducted targeting medical students applying to dermatology residency programs in the United States in the 2025 or 2026 match cycles as well as residents who applied to dermatology residency in the 2021 to 2024 match cycles. The 23-item survey was developed by adapting questions from several validated studies examining research barriers and experiences in medical education.^6,7,10,11 Specifically, the survey included questions on demographics and background; research productivity; general research barriers; conference participation accessibility; mentorship access; and quality, career impact, and support needs. Socioeconomic background was measured via a single self-reported item asking participants to select the income class that best reflected their background growing up (low-income, lower-middle, upper-middle, or high-income); no income ranges were provided.

The survey was distributed electronically via Qualtrics between November 11, 2024, and December 30, 2024, through listserves of the Dermatology Interest Group Association (sent directly to medical students) and the Association of Professors of Dermatology (forwarded to residents by program directors). There was no way to determine the number of dermatology applicants and residents reached through either listserve. The surveys were reviewed and approved by the University of Alabama at Birmingham institutional review board (IRB-300013671).

Statistical analyses were conducted using RStudio (Posit, PBC; version 2024.12.0+467). Descriptive statistics characterized participant demographics and quantified barrier scores using frequencies and proportions. We performed regression analyses to examine relationships between demographic factors and barriers using linear regression; the relationship between barriers and research productivity correlation; and the prediction of specialty change consideration using logistic regression. For all analyses, barrier scores were rated on a scale of 0 to 3 (0=not a barrier, 1=minor barrier, 2=moderate barrier, 3=major barrier); R² values were reported to indicate strength of associations, and statistical significance was set at P<.05.

Results

Participant Demographics—A total of 136 participants completed the survey. Among the respondents, 12% identified as from a background of low-income class, 28% lower-middle class, 49% upper-middle class, and 11% high-income class. Additionally, 27% of respondents identified as underrepresented in medicine (URiM). Regarding debt levels (or expected debt levels) upon graduation from medical school, 32% reported no debt, 9% reported $1000 to $49,000 in debt, 5% reported $50,000 to $99,000 in debt, 15% reported $100,000 to $199,000 in debt, 22% reported $200,000 to $299,000 in debt, and 17% reported $300,000 in debt or higher. The majority of respondents (95%) were MD candidates, and the remaining 5% were DO candidates; additionally, 5% were participants in an MD/PhD program (eTable 1).

Respondents represented various stages of training: 13.2% and 16.2% were third- and fourth-year medical students, respectively, while 6.0%, 20.1%, 18.4%, and 22.8% were postgraduate year (PGY) 1, PGY-2, PGY-3, and PGY-4, respectively. A few respondents (2.9%) were participating in a research year or reapplying to dermatology residency (eTable 2).

Research Barriers and Productivity—Respondents were presented with a list of potential barriers and asked to rate each as not a barrier, a minor barrier, a moderate barrier, or a major barrier. The most common barriers (ie, those with >50% of respondents rating them as a moderate or major) included lack of time, limited access to research opportunities, not knowing how to begin research, and lack of mentorship or support. Lack of time and not knowing where to begin research were reported most frequently as major barriers, with 32% of participants identifying them as such. In contrast, barriers such as financial costs and personal obligations were less frequently rated as major barriers (10% and 4%, respectively), although they still were identified as obstacles by many respondents. Interestingly, most respondents (58%) indicated that institutional limitations were not a barrier, but a separate and sizeable proportion (25%) of respondents considered it to be a major barrier (eFigure 1).

The distributions for all research metrics were right-skewed. The total range was 0 to 45 (median, 6) for number of publications (excluding abstracts), 0 to 33 (median, 2) for published abstracts, 0 to 40 (median, 5) for poster publications, and 0 to 20 (median, 2) for oral presentations (eTable 3).

Regression Analysis—Linear regression analysis identified significant relationships between demographic variables (socioeconomic status [SES], URiM status, and debt level) and individual research barriers. The heatmap in eFigure 2 illustrates the strength of these relationships. Higher SES was predictive of lower reported financial barriers (R²=.2317; P<.0001) and lower reported institutional limitations (R²=.0884; P=.0006). A URiM status predicted higher reported financial barriers (R²=.1097; P<.0001) and institutional limitations (R²=.04537; P=.013). Also, higher debt level predicted increased financial barriers (R²=.2099; P<.0001), institutional limitations (R²=.1258; P<.0001), and lack of mentorship (R²=.06553; P=.003).

Next, the data were evaluated for correlative relationships between individual research barriers and research productivity metrics including number of publications, published abstracts and presentations (oral and poster) and total research output. While correlations were weak or nonsignificant between barriers and most research productivity metrics (published abstracts, oral and poster presentations, and total research output), the number of publications was significantly correlated with several research barriers, including limited access to research opportunities (P=.002), not knowing how to begin research (P=.025), lack of mentorship or support (P=.011), and institutional limitations (P=.042). Higher ratings for limited access to research opportunities, not knowing where to begin research, lack of mentorship or support, and institutional limitations all were negatively correlated with total number of publications (R²=−.27, –.19, −.22, and –.18, respectively)(eFigure 3).

Logistic regression analysis examined the impact of research barriers on the likelihood of specialty change consideration. The results, presented in a forest plot, include odds ratios (ORs) and their corresponding 95% CIs and P values. Lack of time (P=.001) and not knowing where to begin research (P<.001) were the strongest predictors of specialty change consideration (OR, 6.3 and 4.7, ­respectively). Financial cost (P=.043), limited access to research opportunities (P=.006), and lack of mentorship or support (P=.001) also were significant predictors of specialty change consideration (OR, 2.2, 3.1, and 3.5, respectively). Institutional limitations and personal obligations did not predict specialty change consideration (eTable 4 and eFigure 4).

Mitigation Strategies—Mitigation strategies were ranked by respondents based on their perceived importance on a scale of 1 to 7 (1=most important, 7=least important)(eFigure 5). Respondents considered access to engaged mentors to be the most important mitigation strategy by far, with 95% ranking it in the top 3 (47% of respondents ranked it as the top most important mitigation strategy). Financial assistance was the mitigation strategy with the second highest number of respondents (28%) ranking it as the top strategy. Flexible scheduling during rotations, research training programs or discussions, and peer networking and research collaboration opportunities also were considered by respondents to be important mitigation strategies. Time management support/resources frequently was viewed as the least important mitigation strategy, with 38% of respondents ranking it last.

Comment

Our study revealed notable disparities in research barriers among dermatology applicants, with several demonstrating consistent patterns of association with SES, URiM status, and debt burden. Furthermore, the strong relationship between these barriers and decreased research productivity and specialty change consideration suggests that capable candidates may be deterred from pursuing dermatology due to surmountable obstacles rather than lack of interest or ability.

Impact of Demographic Factors on Research Barriers—All 7 general research barriers surveyed were correlated with distinct demographic predictors. Regression analyses indicated that the barrier of financial cost was significantly predicted by lower SES (R²=.2317; P<.001), URiM status (R²=.1097; P<.001), and higher debt levels (R²=.2099; P<.001)(eFigure 2). These findings are particularly concerning given the trend of dermatology applicants pursuing 1-year research fellowships, many of which are unpaid.¹² In fact, Jacobson et al¹¹ found that 71.7% (43/60) of dermatology applicants who pursued a year-long research fellowship experienced financial strain during their fellowship, with many requiring additional loans or drawing from personal savings despite already carrying substantial medical school debt of $200,000 or more. Our findings showcase how financial barriers to research disproportionately affect students from lower socioeconomic backgrounds, those who identify as URiM, and those with higher debt, creating systemic inequities in research access at a time when research productivity is increasingly vital for matching into dermatology. To address these financial barriers, institutions may consider establishing more funded research fellowships or expanding grant programs targeting students from economically disadvantaged and/or underrepresented backgrounds.

Institutional limitations (eg, the absence of a dermatology department) also was a notable barrier that was significantly predicted by lower SES (R²=.0884; P<.001) and URiM status (R²=.04537; P=.013)(eFigure 2). Students at institutions lacking dermatology programs face restricted access to mentorship and research opportunities,¹³ with our results demonstrating that these barriers disproportionately affect students from underresourced and minority groups. These limitations compound disparities in building competitive residency applications.¹⁴ The Women’s Dermatologic Society (WDS) has developed a model for addressing these institutional barriers through its summer research fellowship program for medical students who identify as URiM. By pairing students with WDS mentors who guide them through summer research projects, this initiative addresses access and mentorship gaps for students lacking dermatology departments at their home institution.¹⁵ The WDS program serves as a model for other organizations to adopt and expand, with particular attention to including students who identify as URiM as well as those from lower socioeconomic backgrounds.

Our results identified time constraints and lack of experience as notable research barriers. Higher debt levels significantly predicted both lack of time (R²=.03915; P=.021) and not knowing how to begin research (R²=.0572; P=.005)(eFigure 2). These statistical relationships may be explained by students with higher debt levels needing to prioritize paid work over unpaid research opportunities, limiting their engagement in research due to the scarcity of funded positions.¹² The data further revealed that personal obligations, particularly family care responsibilities, were significantly predicted by both lower SES (R²=.0539; P=.008) and higher debt level (R²=.03237; P=.036)(eFigure 2). These findings demonstrate how students managing academic demands alongside financial and familial responsibilities may face compounded barriers to research engagement. To address these disparities, medical schools may consider implementing protected research time within their curricula; for example, the Emory University School of Medicine (Atlanta, Georgia) has implemented a Discovery Phase program that provides students with 5 months of protected faculty-mentored research time away from academic demands between their third and fourth years of medical school.¹⁶ Integrating similarly structured research periods across medical school curricula could help ensure equitable research opportunities for all students pursuing competitive specialties such as dermatology.⁸

Access to mentorship is a critical determinant of research engagement and productivity, as mentors provide valuable guidance on navigating research processes and professional development.¹⁷ Our analysis revealed that lack of mentorship was predicted by both lower SES (R²=.039; P=.023) and higher debt level (R²=.06553; P=.003)(eFigure 2). Several organizations have developed programs to address these mentorship gaps. The Skin of Color Society pairs medical students with skin of color experts while advancing its mission of increasing diversity in dermatology.¹⁸ Similarly, the American Academy of Dermatology founded a diversity mentorship program that connects students who identify as URiM with dermatologist mentors for summer research experiences.¹⁹ Notably, the Skin of Color Society’s program allows residents to serve as mentors for medical students. Involving residents and community dermatologists as potential dermatology mentors for medical students not only distributes mentorship demands more sustainably but also increases overall access to dermatology mentors. Our findings indicate that similar programs could be expanded to include more residents and community dermatologists as mentors and to target students from disadvantaged backgrounds, those facing financial constraints, and students who identify as URiM. 

Impact of Research Barriers on Career Trajectories—Among survey participants, 35% reported considering changing their specialty choice due to research-related barriers. This substantial percentage likely stems from the escalating pressure to achieve increasingly high research output amidst a lack of sufficient support, time, or tools, as our results suggest. The specific barriers that most notably predicted specialty change consideration were lack of time and not knowing how to begin research (P=.001 and P<.001, respectively). Remarkably, our findings revealed that respondents who rated these as moderate or major barriers were 6.3 and 4.7 times more likely to consider changing their specialty choice, respectively. Respondents reporting financial cost (P=.043), limited access to research opportunities (P=.006), and lack of mentorship or support (P=.001) as at least moderate barriers also were 2.2 to 3.5 times more likely to consider a specialty change (eTable 4 and eFigure 4). Additionally, barriers such as limited access to research opportunities (R²=−.27; P=.002), lack of mentorship (R²=−.22; P=.011), not knowing how to begin research (R²=−.19; P=.025), and institutional limitations (R²=−.18; P=.042) all were associated with lower publication output according to our data (eFigure 3). These findings are especially concerning given current match statistics, where the trajectory of research productivity required for a successful dermatology match continues to rise sharply.^3,4

Alarmingly, many of the barriers we identified—linked to both reduced research output and specialty change consideration—are associated with several demographic factors. Higher debt levels predicted greater likelihood of experiencing lack of time, insufficient mentorship, and uncertainty about initiating research, while lower SES was associated with lack of mentorship. These relationships suggest that structural barriers, rather than lack of interest or ability, may create cumulative disadvantages that deter capable candidates from pursuing dermatology or impact their success in the application process.

One potential solution to address the disproportionate emphasis on research quantity would be implementing caps on reportable research products in residency applications (eg, limiting applications to a certain number of publications, abstracts, and presentations). This change could shift applicant focus toward substantive scientific contributions rather than rapid output accumulation.⁸ The need for such caps was evident in our dataset, which revealed a stark contrast: some respondents reported 30 to 40 publications, while MD/PhD respondents—who dedicate 3 to 5 years to performing quality research—averaged only 7.4 publications. Implementing a research output ceiling could help alleviate barriers for applicants facing institutional and demographic disadvantages while simultaneously boosting the scientific rigor of dermatology research.⁸

Mitigation Strategies From Applicant Feedback—Our findings emphasize the multifaceted relationship between structural barriers and demographics in dermatology research engagement. While our statistical interpretations have outlined several potential interventions, the applicants’ perspectives on mitigation strategies offer qualitative insight. Although participants did not consistently mark financial cost and lack of mentorship as major barriers (eFigure 1), financial assistance and access to engaged mentors were among the highest-ranked mitigation strategies (eFigure 5), suggesting these resources may be fundamental to overcoming multiple structural challenges. To address these needs comprehensively, we propose a multilevel approach: at the institutional level, dermatology interest groups could establish centralized databases of research opportunities, mentorship programs, and funding sources. At the national level, dermatology organizations could consider expanding grant programs, developing virtual mentorship networks, and creating opportunities for external students through remote research projects or short-term research rotations. These interventions, informed by both our statistical analyses and applicant feedback, could help create more equitable access to research opportunities in dermatology.

Limitations

A major limitation of this study was that potential dermatology candidates who were deterred by barriers and later decided on a different specialty would not be captured in our data. As these candidates may have faced substantial barriers that caused them to choose a different path, their absence from the current data may indicate that the reported results underpredict the effect size of the true population. Another limitation is the absence of a control group, such as applicants to less competitive specialties, which would provide valuable context for whether the barriers identified are unique to dermatology.

Conclusion

Our study provides compelling evidence that research barriers in dermatology residency applications intersect with demographic factors to influence research engagement and career trajectories. Our findings suggest that without targeted intervention, increasing emphasis on research productivity may exacerbate existing disparities in dermatology. Moving forward, a coordinated effort among institutions, dermatology associations, and dermatology residency programs will be fundamental to ensure that research requirements enhance rather than impede the development of a diverse, qualified dermatology workforce.

As one of the most competitive specialties in medicine, dermatology presents unique challenges for residency applicants, especially following the shift in United States Medical Licensing Examination (USMLE) Step 1 scoring to a pass/fail format.^1,2 Historically, USMLE Step 1 served as a major screening metric for residency programs, with 90% of program directors in 2020 using USMLE Step 1 scores as a primary factor when deciding whether to invite applicants for interviews.¹ However, the recent transition to pass/fail has made it much harder for program directors to objectively compare applicants, particularly in dermatology. In a 2020 survey, Patrinely Jr et al² found that 77.2% of dermatology program directors agreed that this change would make it more difficult to assess candidates objectively. Consequently, research productivity has taken on greater importance as programs seek new ways to distinguish top applicants.^1,2

In response to this increased emphasis on research, dermatology applicants have substantially boosted their scholarly output over the past several years. The 2022 and 2024 results from the National Residency Matching Program’s Charting Outcomes survey demonstrated a steady rise in research metrics among applicants across various specialties, with dermatology showing one of the largest increases.^3,4 For instance, the average number of abstracts, presentations, and publications for matched allopathic dermatology applicants was 5.7 in 2007.⁵ This average increased to 20.9 in 2022³ and to 27.7 in 2024,⁴ marking an astonishing 485% increase in 17 years. Interestingly, unmatched dermatology applicants had an average of 19.0 research products in 2024, which was similar to the average of successfully matched applicants just 2 years earlier.^3,4

Engaging in research offers benefits beyond building a strong residency application. Specifically, it enhances critical thinking skills and provides hands-on experience in scientific inquiry.⁶ It allows students to explore dermatology topics of interest and address existing knowledge gaps within the specialty.⁶ Additionally, it creates opportunities to build meaningful relationships with experienced dermatologists who can guide and support students throughout their careers.⁷ Despite these benefits, the pursuit of research may be landscaped with obstacles, and the fervent race to obtain high research outputs may overshadow developmental advantages.⁸ These challenges and demands also could contribute to inequities in the residency selection process, particularly if barriers are influenced by socioeconomic and demographic disparities. As dermatology already ranks as the second least diverse specialty in medicine,⁹ research requirements that disproportionately disadvantage certain demographic groups risk further widening these concerning representation gaps rather than creating opportunities to address them.

Given these trends in research requirements and their potential impact on applicant success, understanding specific barriers to research engagement is essential for creating equitable opportunities in dermatology. In this study, we aimed to identify barriers to research engagement among dermatology applicants, analyze their relationship with demographic factors, assess their impact on specialty choice and research productivity, and provide actionable solutions to address these obstacles.

Methods

A cross-sectional survey was conducted targeting medical students applying to dermatology residency programs in the United States in the 2025 or 2026 match cycles as well as residents who applied to dermatology residency in the 2021 to 2024 match cycles. The 23-item survey was developed by adapting questions from several validated studies examining research barriers and experiences in medical education.^6,7,10,11 Specifically, the survey included questions on demographics and background; research productivity; general research barriers; conference participation accessibility; mentorship access; and quality, career impact, and support needs. Socioeconomic background was measured via a single self-reported item asking participants to select the income class that best reflected their background growing up (low-income, lower-middle, upper-middle, or high-income); no income ranges were provided.

The survey was distributed electronically via Qualtrics between November 11, 2024, and December 30, 2024, through listserves of the Dermatology Interest Group Association (sent directly to medical students) and the Association of Professors of Dermatology (forwarded to residents by program directors). There was no way to determine the number of dermatology applicants and residents reached through either listserve. The surveys were reviewed and approved by the University of Alabama at Birmingham institutional review board (IRB-300013671).

Statistical analyses were conducted using RStudio (Posit, PBC; version 2024.12.0+467). Descriptive statistics characterized participant demographics and quantified barrier scores using frequencies and proportions. We performed regression analyses to examine relationships between demographic factors and barriers using linear regression; the relationship between barriers and research productivity correlation; and the prediction of specialty change consideration using logistic regression. For all analyses, barrier scores were rated on a scale of 0 to 3 (0=not a barrier, 1=minor barrier, 2=moderate barrier, 3=major barrier); R² values were reported to indicate strength of associations, and statistical significance was set at P<.05.

Results

Participant Demographics—A total of 136 participants completed the survey. Among the respondents, 12% identified as from a background of low-income class, 28% lower-middle class, 49% upper-middle class, and 11% high-income class. Additionally, 27% of respondents identified as underrepresented in medicine (URiM). Regarding debt levels (or expected debt levels) upon graduation from medical school, 32% reported no debt, 9% reported $1000 to $49,000 in debt, 5% reported $50,000 to $99,000 in debt, 15% reported $100,000 to $199,000 in debt, 22% reported $200,000 to $299,000 in debt, and 17% reported $300,000 in debt or higher. The majority of respondents (95%) were MD candidates, and the remaining 5% were DO candidates; additionally, 5% were participants in an MD/PhD program (eTable 1).

Respondents represented various stages of training: 13.2% and 16.2% were third- and fourth-year medical students, respectively, while 6.0%, 20.1%, 18.4%, and 22.8% were postgraduate year (PGY) 1, PGY-2, PGY-3, and PGY-4, respectively. A few respondents (2.9%) were participating in a research year or reapplying to dermatology residency (eTable 2).

Research Barriers and Productivity—Respondents were presented with a list of potential barriers and asked to rate each as not a barrier, a minor barrier, a moderate barrier, or a major barrier. The most common barriers (ie, those with >50% of respondents rating them as a moderate or major) included lack of time, limited access to research opportunities, not knowing how to begin research, and lack of mentorship or support. Lack of time and not knowing where to begin research were reported most frequently as major barriers, with 32% of participants identifying them as such. In contrast, barriers such as financial costs and personal obligations were less frequently rated as major barriers (10% and 4%, respectively), although they still were identified as obstacles by many respondents. Interestingly, most respondents (58%) indicated that institutional limitations were not a barrier, but a separate and sizeable proportion (25%) of respondents considered it to be a major barrier (eFigure 1).

The distributions for all research metrics were right-skewed. The total range was 0 to 45 (median, 6) for number of publications (excluding abstracts), 0 to 33 (median, 2) for published abstracts, 0 to 40 (median, 5) for poster publications, and 0 to 20 (median, 2) for oral presentations (eTable 3).

Regression Analysis—Linear regression analysis identified significant relationships between demographic variables (socioeconomic status [SES], URiM status, and debt level) and individual research barriers. The heatmap in eFigure 2 illustrates the strength of these relationships. Higher SES was predictive of lower reported financial barriers (R²=.2317; P<.0001) and lower reported institutional limitations (R²=.0884; P=.0006). A URiM status predicted higher reported financial barriers (R²=.1097; P<.0001) and institutional limitations (R²=.04537; P=.013). Also, higher debt level predicted increased financial barriers (R²=.2099; P<.0001), institutional limitations (R²=.1258; P<.0001), and lack of mentorship (R²=.06553; P=.003).

Next, the data were evaluated for correlative relationships between individual research barriers and research productivity metrics including number of publications, published abstracts and presentations (oral and poster) and total research output. While correlations were weak or nonsignificant between barriers and most research productivity metrics (published abstracts, oral and poster presentations, and total research output), the number of publications was significantly correlated with several research barriers, including limited access to research opportunities (P=.002), not knowing how to begin research (P=.025), lack of mentorship or support (P=.011), and institutional limitations (P=.042). Higher ratings for limited access to research opportunities, not knowing where to begin research, lack of mentorship or support, and institutional limitations all were negatively correlated with total number of publications (R²=−.27, –.19, −.22, and –.18, respectively)(eFigure 3).

Logistic regression analysis examined the impact of research barriers on the likelihood of specialty change consideration. The results, presented in a forest plot, include odds ratios (ORs) and their corresponding 95% CIs and P values. Lack of time (P=.001) and not knowing where to begin research (P<.001) were the strongest predictors of specialty change consideration (OR, 6.3 and 4.7, ­respectively). Financial cost (P=.043), limited access to research opportunities (P=.006), and lack of mentorship or support (P=.001) also were significant predictors of specialty change consideration (OR, 2.2, 3.1, and 3.5, respectively). Institutional limitations and personal obligations did not predict specialty change consideration (eTable 4 and eFigure 4).

Mitigation Strategies—Mitigation strategies were ranked by respondents based on their perceived importance on a scale of 1 to 7 (1=most important, 7=least important)(eFigure 5). Respondents considered access to engaged mentors to be the most important mitigation strategy by far, with 95% ranking it in the top 3 (47% of respondents ranked it as the top most important mitigation strategy). Financial assistance was the mitigation strategy with the second highest number of respondents (28%) ranking it as the top strategy. Flexible scheduling during rotations, research training programs or discussions, and peer networking and research collaboration opportunities also were considered by respondents to be important mitigation strategies. Time management support/resources frequently was viewed as the least important mitigation strategy, with 38% of respondents ranking it last.

Comment

Our study revealed notable disparities in research barriers among dermatology applicants, with several demonstrating consistent patterns of association with SES, URiM status, and debt burden. Furthermore, the strong relationship between these barriers and decreased research productivity and specialty change consideration suggests that capable candidates may be deterred from pursuing dermatology due to surmountable obstacles rather than lack of interest or ability.

Impact of Demographic Factors on Research Barriers—All 7 general research barriers surveyed were correlated with distinct demographic predictors. Regression analyses indicated that the barrier of financial cost was significantly predicted by lower SES (R²=.2317; P<.001), URiM status (R²=.1097; P<.001), and higher debt levels (R²=.2099; P<.001)(eFigure 2). These findings are particularly concerning given the trend of dermatology applicants pursuing 1-year research fellowships, many of which are unpaid.¹² In fact, Jacobson et al¹¹ found that 71.7% (43/60) of dermatology applicants who pursued a year-long research fellowship experienced financial strain during their fellowship, with many requiring additional loans or drawing from personal savings despite already carrying substantial medical school debt of $200,000 or more. Our findings showcase how financial barriers to research disproportionately affect students from lower socioeconomic backgrounds, those who identify as URiM, and those with higher debt, creating systemic inequities in research access at a time when research productivity is increasingly vital for matching into dermatology. To address these financial barriers, institutions may consider establishing more funded research fellowships or expanding grant programs targeting students from economically disadvantaged and/or underrepresented backgrounds.

Institutional limitations (eg, the absence of a dermatology department) also was a notable barrier that was significantly predicted by lower SES (R²=.0884; P<.001) and URiM status (R²=.04537; P=.013)(eFigure 2). Students at institutions lacking dermatology programs face restricted access to mentorship and research opportunities,¹³ with our results demonstrating that these barriers disproportionately affect students from underresourced and minority groups. These limitations compound disparities in building competitive residency applications.¹⁴ The Women’s Dermatologic Society (WDS) has developed a model for addressing these institutional barriers through its summer research fellowship program for medical students who identify as URiM. By pairing students with WDS mentors who guide them through summer research projects, this initiative addresses access and mentorship gaps for students lacking dermatology departments at their home institution.¹⁵ The WDS program serves as a model for other organizations to adopt and expand, with particular attention to including students who identify as URiM as well as those from lower socioeconomic backgrounds.

Our results identified time constraints and lack of experience as notable research barriers. Higher debt levels significantly predicted both lack of time (R²=.03915; P=.021) and not knowing how to begin research (R²=.0572; P=.005)(eFigure 2). These statistical relationships may be explained by students with higher debt levels needing to prioritize paid work over unpaid research opportunities, limiting their engagement in research due to the scarcity of funded positions.¹² The data further revealed that personal obligations, particularly family care responsibilities, were significantly predicted by both lower SES (R²=.0539; P=.008) and higher debt level (R²=.03237; P=.036)(eFigure 2). These findings demonstrate how students managing academic demands alongside financial and familial responsibilities may face compounded barriers to research engagement. To address these disparities, medical schools may consider implementing protected research time within their curricula; for example, the Emory University School of Medicine (Atlanta, Georgia) has implemented a Discovery Phase program that provides students with 5 months of protected faculty-mentored research time away from academic demands between their third and fourth years of medical school.¹⁶ Integrating similarly structured research periods across medical school curricula could help ensure equitable research opportunities for all students pursuing competitive specialties such as dermatology.⁸

Access to mentorship is a critical determinant of research engagement and productivity, as mentors provide valuable guidance on navigating research processes and professional development.¹⁷ Our analysis revealed that lack of mentorship was predicted by both lower SES (R²=.039; P=.023) and higher debt level (R²=.06553; P=.003)(eFigure 2). Several organizations have developed programs to address these mentorship gaps. The Skin of Color Society pairs medical students with skin of color experts while advancing its mission of increasing diversity in dermatology.¹⁸ Similarly, the American Academy of Dermatology founded a diversity mentorship program that connects students who identify as URiM with dermatologist mentors for summer research experiences.¹⁹ Notably, the Skin of Color Society’s program allows residents to serve as mentors for medical students. Involving residents and community dermatologists as potential dermatology mentors for medical students not only distributes mentorship demands more sustainably but also increases overall access to dermatology mentors. Our findings indicate that similar programs could be expanded to include more residents and community dermatologists as mentors and to target students from disadvantaged backgrounds, those facing financial constraints, and students who identify as URiM. 

Impact of Research Barriers on Career Trajectories—Among survey participants, 35% reported considering changing their specialty choice due to research-related barriers. This substantial percentage likely stems from the escalating pressure to achieve increasingly high research output amidst a lack of sufficient support, time, or tools, as our results suggest. The specific barriers that most notably predicted specialty change consideration were lack of time and not knowing how to begin research (P=.001 and P<.001, respectively). Remarkably, our findings revealed that respondents who rated these as moderate or major barriers were 6.3 and 4.7 times more likely to consider changing their specialty choice, respectively. Respondents reporting financial cost (P=.043), limited access to research opportunities (P=.006), and lack of mentorship or support (P=.001) as at least moderate barriers also were 2.2 to 3.5 times more likely to consider a specialty change (eTable 4 and eFigure 4). Additionally, barriers such as limited access to research opportunities (R²=−.27; P=.002), lack of mentorship (R²=−.22; P=.011), not knowing how to begin research (R²=−.19; P=.025), and institutional limitations (R²=−.18; P=.042) all were associated with lower publication output according to our data (eFigure 3). These findings are especially concerning given current match statistics, where the trajectory of research productivity required for a successful dermatology match continues to rise sharply.^3,4

Alarmingly, many of the barriers we identified—linked to both reduced research output and specialty change consideration—are associated with several demographic factors. Higher debt levels predicted greater likelihood of experiencing lack of time, insufficient mentorship, and uncertainty about initiating research, while lower SES was associated with lack of mentorship. These relationships suggest that structural barriers, rather than lack of interest or ability, may create cumulative disadvantages that deter capable candidates from pursuing dermatology or impact their success in the application process.

One potential solution to address the disproportionate emphasis on research quantity would be implementing caps on reportable research products in residency applications (eg, limiting applications to a certain number of publications, abstracts, and presentations). This change could shift applicant focus toward substantive scientific contributions rather than rapid output accumulation.⁸ The need for such caps was evident in our dataset, which revealed a stark contrast: some respondents reported 30 to 40 publications, while MD/PhD respondents—who dedicate 3 to 5 years to performing quality research—averaged only 7.4 publications. Implementing a research output ceiling could help alleviate barriers for applicants facing institutional and demographic disadvantages while simultaneously boosting the scientific rigor of dermatology research.⁸

Mitigation Strategies From Applicant Feedback—Our findings emphasize the multifaceted relationship between structural barriers and demographics in dermatology research engagement. While our statistical interpretations have outlined several potential interventions, the applicants’ perspectives on mitigation strategies offer qualitative insight. Although participants did not consistently mark financial cost and lack of mentorship as major barriers (eFigure 1), financial assistance and access to engaged mentors were among the highest-ranked mitigation strategies (eFigure 5), suggesting these resources may be fundamental to overcoming multiple structural challenges. To address these needs comprehensively, we propose a multilevel approach: at the institutional level, dermatology interest groups could establish centralized databases of research opportunities, mentorship programs, and funding sources. At the national level, dermatology organizations could consider expanding grant programs, developing virtual mentorship networks, and creating opportunities for external students through remote research projects or short-term research rotations. These interventions, informed by both our statistical analyses and applicant feedback, could help create more equitable access to research opportunities in dermatology.

Limitations

A major limitation of this study was that potential dermatology candidates who were deterred by barriers and later decided on a different specialty would not be captured in our data. As these candidates may have faced substantial barriers that caused them to choose a different path, their absence from the current data may indicate that the reported results underpredict the effect size of the true population. Another limitation is the absence of a control group, such as applicants to less competitive specialties, which would provide valuable context for whether the barriers identified are unique to dermatology.

Conclusion

Our study provides compelling evidence that research barriers in dermatology residency applications intersect with demographic factors to influence research engagement and career trajectories. Our findings suggest that without targeted intervention, increasing emphasis on research productivity may exacerbate existing disparities in dermatology. Moving forward, a coordinated effort among institutions, dermatology associations, and dermatology residency programs will be fundamental to ensure that research requirements enhance rather than impede the development of a diverse, qualified dermatology workforce.

While strong relationships with mentors and advisers are critical to navigating the competitive dermatology match process, the advice medical students receive from different individuals can be contradictory. Unaccredited information online—particularly on social media—as well as data reported by applicants can add to potential confusion.¹ Published research has elicited comments and observations from successfully matched medical students about highly discussed topics such as presentations and publications, letters of recommendation, away rotations, and interviews.^2,3 However, there currently are no published data about advice that dermatology mentors actually offer medical students. In this study, we aimed to investigate this gap in the current literature and examine the advice dermatology faculty, program directors, and other mentors at institutions accredited by the Accreditation Council for Graduate Medical Education across the United States give to medical students applying to dermatology residency.

Methods

A 14-question Johns Hopkins Qualtrics survey was sent via the Association of Professors of Dermatology (APD) listserve in June 2024 soliciting responses from members who consider themselves to be mentors to dermatology applicants across the United States. The survey included multiple-choice questions with the option to select multiple answers and a space for open-ended responses. The questions first gathered information on the respondents, including the capacity in which the mentors advised medical students (eg, program director, department chair, clinical faculty). Mentors were asked for the number of years they had been advising mentees and if they were advising students with a home dermatology program. In addition, mentors were asked what advice they give their mentees about aspects of the application process, including gap years, dual applications, research involvement, couples matching, program signaling, away rotations, internship year, letters of recommendation, geographic signaling, interviewing advice, and volunteering during medical school.

On August 18, 2024, survey results from 115 respondents were aggregated. The responses for each question were quantitatively assessed to determine whether there was consensus on specific advice offered. The open-ended responses also were qualitatively assessed to determine the most common responses.

Results

The respondents included program directors (30% [35/115]), clinical faculty (22% [25/115]), department chairs (18% [21/115]), assistant program directors (15% [17/115]), medical school clerkship directors (8% [9/115]), primary mentors (ie, faculty who did not fall into any of the aforementioned categories but still advised medical students interested in dermatology)(5% [6/115]), division chiefs (1% [1/115]), and deans (1% [1/115]). Respondents had been advising students for a median of 10 years (range, 1-40 years [25th percentile, 5.00 years; 75th percentile, 13.75 years]). The majority (90% [103/115]) of mentors surveyed were advising students with a home dermatology program.

Areas of Consensus

In some areas, there was broad consensus among the advice offered by the mentors that were surveyed (eTable).

Research During Medical School—More than 91% (105/115) of the respondents recommended research to encourage academic growth and indicated that the most important reason for conducting research during medical school is to foster mentor-mentee relationships; however, more than one-third of respondents believed research is overvalued by students and research productivity is not as critical for matching as they perceive it to be. When these responses were categorized by respondent positions, 29% (15/52) of program or assistant directors indicated agreement with the statement that research is overvalued.

Away Rotations—There also was a consensus about the importance of away rotations, with 85% (98/115) of respondents advising students to complete 1 to 2 away rotations at sites of high interest, and 13% (15/115) suggesting that students complete as many away rotations as possible. It is worth noting, however, that the official APD Residency Program Directors Section’s statement on away rotations recommends no more than 2 away rotations (or no more than 3 for students with no home program).⁴

Reapplication Advice—Additionally, in a situation where students do not match into a dermatology residency program, the vast majority (71% [82/115]) of respondents advised students to rank competitive intern years to foster connections and improve the chance of matching on the second attempt.

Volunteering During Medical School—Seventy-seven percent (89/115) of mentors encouraged students to engage in volunteerism and advocacy during medical school to create a well-rounded application, and 69% (79/115) of mentors encouraged students to display leadership in their volunteer efforts.

Areas Without Consensus

Letters of Recommendation—Most respondents recommended submitting letters of recommendation only from dermatology professionals (55% [63/115]), with the remainder recommending students request a letter from anyone who could provide a strong recommendation regardless of specialty mix (42% [48/115]).

Dermatologic Subspecialties—For students interested in dermatologic subspecialties, 73% (84/115) of mentors advised that students be honest during interviews but keep an open mind that interests during residencies may change. Forty-three percent (49/115) of respondents encouraged students to promote a subspecialty interest during their interview only if they can demonstrate effort within that subspecialty on their application.

Couples Matching—Most respondents approach couples matching on a case-by-case basis and assess individual priorities when they do advise on this topic. Respondents often advise applicants to identify a few cities/regions and focus strongly on the programs within those regions to avoid spreading themselves too thin; however, one-third (38/115) of respondents indicated that they do not personally offer advice regarding the couples match.

Areas With Diverse Opinions

Gap Years—Nearly one-quarter (24% [28/115]) of mentors reported that they rarely recommend students take a year off and only support those who are adamant about doing so, or that they never support taking a gap year at all. A slight majority (58% [67/115]) recommend a gap year for students strongly interested in dermatologic research, and 38% (44/115) recommend a gap year for students with weaker applications (Figure 1). We received many open-ended responses to this question, with mentors frequently indicating that they advise students to take a gap year on a case-by-case basis, with 44% (51/115) of commenters recommending that students only take paid gap-year research positions.

Program Signaling—The dermatology residency application process implemented a system of preference signaling tokens (PSTs) starting with the 2021-2022 cycle. Not quite half (46% [53/115]) of respondents recommend students apply only to places that they signaled, while 20% (23/115) advise responding to 10 to 15 additional programs. Very few (8% [9/115]) advise students to signal only in their stated region of interest. Approximately half (49% [56/115]) of mentors recommend students only signal based on the programs they feel would be the best fit for them without regard for perceived competitiveness—which aligns with the APD Residency Program Directors Section’s recommendation⁴—while 37% (43/115) recommend students distribute their signals to a wide range of programs. Sixty-three percent (72/115) of respondents recommend gold signaling to the student’s 3 most desired programs regardless of home and away rotation considerations, while 19% (22/115) recommend students give silver signals to their home and away rotation programs, as a rotation is already a signal of a strong desire to be there (Figure 2).

Dual Application—Fifty-three percent (61/115) of mentors recommended dual applying only for those truly interested in multiple specialties. Eighteen percent (21/115) of respondents advised dual applying for those with less than a 75% chance of matching. Twenty-five percent (29/115) of respondents free-wrote comments about approaching dual applying on a case-by-case basis, with many discussing the downsides of dual application and raising concerns that dual applications can hinder applicants’ success, can seem disingenuous, and seem to be a tool used to improve medical school match rates without benefit for the student.

We also stratified the data to compare overall responses from the total cohort with those from only program and assistant program directors. Across the 14 questions, responses from program and assistant program directors alone were similar to the overall cohort results

Comment

This study evaluated nationwide data on mentorship advising in dermatology, detailing mentors’ advice regarding research, gap years, dual applications, away rotations, intern year, couples matching, program signaling, and volunteering during medical school. Based on our results, most respondents agree on the importance of research during medical school, the utility of away rotations, and the value of volunteering during medical school. Similarly, respondents agreed on the importance of having strong letters of recommendation; while some advised asking only dermatology faculty to write letters, others did not have a specialty preference for the letter writers. Respondents also had varying views about sharing interest in subspecialties during residency interviews. Many of the respondents do not provide recommendations regarding geographic signaling and couples matching, expressing that these are parts of an application that are important to approach on a case-by-case basis. Lastly, respondents had diverse opinions regarding the utility of gap years, whether to encourage or discourage dual applications, and how to advise regarding program signaling.

Our results also showed that one-third of respondents believed that research is not as important as it is perceived to be by dermatology applicants. While engaging in research during medical school was almost unanimously encouraged to foster mentor-mentee relationships, respondents expressed that the number of research experiences and publications was not critical. This is an important topic of discussion, as taking a dedicated year away from medical school to complete a research fellowship is becoming a trend among dermatology applicants.⁵ There has been discussion both on unofficial online platforms as well as in the published literature regarding the pressure for medical students interested in dermatology to publish, which may result in a gap year for research.⁶ The literature on the utility of a gap year in match rates is sparse, with one study showing no difference in match rates among Mayo Clinic dermatology residents who took research years vs those who did not.⁷ However, this contrasts with match rates at top dermatology residency programs where 41% of applicants who took a gap year matched vs 19% who did not.^7,8 These conflicting data are reflected in our study results, with respondents expressing different opinions on the utility of gap years.

There also are important equity concerns regarding the role of research years in the dermatology residency match process. Dermatology is one of the least racially diverse specialties, although there have been efforts to increase representation among residents and attending physicians.^9-11 Research years can be important contributors to this lack of representation, as these often are unpaid and can discourage economically disadvantaged students from applying.^9-11 Additionally, applicants may not have the flexibility to defer future salary for a year to match into dermatology; therefore, mentors should offer multiple options to individual applicants instead of solely encouraging gap years, given the conflicting feelings regarding their productivity.

Another topic of disagreement was dual application. Approximately one-third of respondents said they encourage either all students or those with less than a 75% chance of matching to dual apply, while about half only encourage students who are truly interested in multiple specialties to do so. Additionally, a large subset of respondents said they do not encourage dual applications due to concerns that they make applicants a worse candidate for each specialty and overall have negative effects on matching. Twenty-five percent of respondents opted to leave an open-ended response to this question: some offered the perspective that, if applicants feel a need to dual apply due to a weaker application, they do not advise the applicant to apply to dermatology. Many open ended responses underscored that the respondent does not encourage dual applications because they are inherently more time consuming, could hinder the applicant’s success, can seem disingenuous, and are a tool used to improve medical school match rates without being beneficial for the student. Some respondents also favored reapplying to dermatology the following year instead of dual applying. Finally, a subset of mentors indicated that they approach dual applications on a case-by-case basis, and others reported they do not have much experience advising on this topic. Currently, there are no known data in the literature on the efficacy and utility of dual applications in the dermatology match process; therefore, our study provides valuable insight for applicants interested in the impacts of the dual application. Overall, students should approach this option with mentors on an individual basis but ultimately should be aware of the concerns and mixed perceptions of the dual application process.

With regard to program signaling, previous research has shown that PSTs have a large impact on the chance of being granted an interview.¹² In our study, we provide a comprehensive overview of advising regarding these signals. While mentors often responded that they did not have much experience advising in this domain—and it is too soon to tell the impact of this program signaling—many offered differing opinions. Many said they recommend that students give a gold signal to their 3 most desired programs regardless of home and away rotations and perceived competitiveness, which follows the guidelines issued by the APD; however, 19% recommend only giving silver signals to home and away rotation programs, as participation in those programs is considered a sufficient signal of interest. Additionally, about half of mentors recommended that students only apply where they signal, whereas 20% recommended applying to 10 to 15 programs beyond those signaled. Future studies should investigate the impact of PSTs on interview invitations once sufficient application cycles have occurred.

Study Limitations

This study was conducted via email to the APD listserve. The total number of faculty on this listserve is unknown; therefore, we do not know the total response rate of the survey. Additionally, we surveyed mentors in this listserve, who therefore receive more emails and overall correspondence about the dermatology match and may be more involved in these conversations. The mentors who responded to our survey may have a different approach and response to our various survey questions than a given mentor across the United States who did not respond to this survey. A final limitation of our study is that the survey responses a mentor gives may not fully match the advice that they give their students privately.

Conclusion

Our survey of dermatology mentors across the United States provides valuable insight into how mentors advise for a strong dermatology residency application. Mentors agreed on the importance of research during medical school, away rotations, strong letters of recommendation, and volunteerism and advocacy to promote a strong residency application. Important topics of disagreement include the decision for dermatology applicants to take a dedicated gap year in medical school, how to use tokens/signals effectively, and the dual application process. Our findings also underscore important application components that applicants and mentors should approach on an individual basis. Future studies should investigate the impact of signals/tokens on the match process as well as the utility of gap years and dual applications, working to standardize the advice applicants receive.

While strong relationships with mentors and advisers are critical to navigating the competitive dermatology match process, the advice medical students receive from different individuals can be contradictory. Unaccredited information online—particularly on social media—as well as data reported by applicants can add to potential confusion.¹ Published research has elicited comments and observations from successfully matched medical students about highly discussed topics such as presentations and publications, letters of recommendation, away rotations, and interviews.^2,3 However, there currently are no published data about advice that dermatology mentors actually offer medical students. In this study, we aimed to investigate this gap in the current literature and examine the advice dermatology faculty, program directors, and other mentors at institutions accredited by the Accreditation Council for Graduate Medical Education across the United States give to medical students applying to dermatology residency.

Methods

A 14-question Johns Hopkins Qualtrics survey was sent via the Association of Professors of Dermatology (APD) listserve in June 2024 soliciting responses from members who consider themselves to be mentors to dermatology applicants across the United States. The survey included multiple-choice questions with the option to select multiple answers and a space for open-ended responses. The questions first gathered information on the respondents, including the capacity in which the mentors advised medical students (eg, program director, department chair, clinical faculty). Mentors were asked for the number of years they had been advising mentees and if they were advising students with a home dermatology program. In addition, mentors were asked what advice they give their mentees about aspects of the application process, including gap years, dual applications, research involvement, couples matching, program signaling, away rotations, internship year, letters of recommendation, geographic signaling, interviewing advice, and volunteering during medical school.

On August 18, 2024, survey results from 115 respondents were aggregated. The responses for each question were quantitatively assessed to determine whether there was consensus on specific advice offered. The open-ended responses also were qualitatively assessed to determine the most common responses.

Results

The respondents included program directors (30% [35/115]), clinical faculty (22% [25/115]), department chairs (18% [21/115]), assistant program directors (15% [17/115]), medical school clerkship directors (8% [9/115]), primary mentors (ie, faculty who did not fall into any of the aforementioned categories but still advised medical students interested in dermatology)(5% [6/115]), division chiefs (1% [1/115]), and deans (1% [1/115]). Respondents had been advising students for a median of 10 years (range, 1-40 years [25th percentile, 5.00 years; 75th percentile, 13.75 years]). The majority (90% [103/115]) of mentors surveyed were advising students with a home dermatology program.

Areas of Consensus

In some areas, there was broad consensus among the advice offered by the mentors that were surveyed (eTable).

Research During Medical School—More than 91% (105/115) of the respondents recommended research to encourage academic growth and indicated that the most important reason for conducting research during medical school is to foster mentor-mentee relationships; however, more than one-third of respondents believed research is overvalued by students and research productivity is not as critical for matching as they perceive it to be. When these responses were categorized by respondent positions, 29% (15/52) of program or assistant directors indicated agreement with the statement that research is overvalued.

Away Rotations—There also was a consensus about the importance of away rotations, with 85% (98/115) of respondents advising students to complete 1 to 2 away rotations at sites of high interest, and 13% (15/115) suggesting that students complete as many away rotations as possible. It is worth noting, however, that the official APD Residency Program Directors Section’s statement on away rotations recommends no more than 2 away rotations (or no more than 3 for students with no home program).⁴

Reapplication Advice—Additionally, in a situation where students do not match into a dermatology residency program, the vast majority (71% [82/115]) of respondents advised students to rank competitive intern years to foster connections and improve the chance of matching on the second attempt.

Volunteering During Medical School—Seventy-seven percent (89/115) of mentors encouraged students to engage in volunteerism and advocacy during medical school to create a well-rounded application, and 69% (79/115) of mentors encouraged students to display leadership in their volunteer efforts.

Areas Without Consensus

Letters of Recommendation—Most respondents recommended submitting letters of recommendation only from dermatology professionals (55% [63/115]), with the remainder recommending students request a letter from anyone who could provide a strong recommendation regardless of specialty mix (42% [48/115]).

Dermatologic Subspecialties—For students interested in dermatologic subspecialties, 73% (84/115) of mentors advised that students be honest during interviews but keep an open mind that interests during residencies may change. Forty-three percent (49/115) of respondents encouraged students to promote a subspecialty interest during their interview only if they can demonstrate effort within that subspecialty on their application.

Couples Matching—Most respondents approach couples matching on a case-by-case basis and assess individual priorities when they do advise on this topic. Respondents often advise applicants to identify a few cities/regions and focus strongly on the programs within those regions to avoid spreading themselves too thin; however, one-third (38/115) of respondents indicated that they do not personally offer advice regarding the couples match.

Areas With Diverse Opinions

Gap Years—Nearly one-quarter (24% [28/115]) of mentors reported that they rarely recommend students take a year off and only support those who are adamant about doing so, or that they never support taking a gap year at all. A slight majority (58% [67/115]) recommend a gap year for students strongly interested in dermatologic research, and 38% (44/115) recommend a gap year for students with weaker applications (Figure 1). We received many open-ended responses to this question, with mentors frequently indicating that they advise students to take a gap year on a case-by-case basis, with 44% (51/115) of commenters recommending that students only take paid gap-year research positions.

Program Signaling—The dermatology residency application process implemented a system of preference signaling tokens (PSTs) starting with the 2021-2022 cycle. Not quite half (46% [53/115]) of respondents recommend students apply only to places that they signaled, while 20% (23/115) advise responding to 10 to 15 additional programs. Very few (8% [9/115]) advise students to signal only in their stated region of interest. Approximately half (49% [56/115]) of mentors recommend students only signal based on the programs they feel would be the best fit for them without regard for perceived competitiveness—which aligns with the APD Residency Program Directors Section’s recommendation⁴—while 37% (43/115) recommend students distribute their signals to a wide range of programs. Sixty-three percent (72/115) of respondents recommend gold signaling to the student’s 3 most desired programs regardless of home and away rotation considerations, while 19% (22/115) recommend students give silver signals to their home and away rotation programs, as a rotation is already a signal of a strong desire to be there (Figure 2).

Dual Application—Fifty-three percent (61/115) of mentors recommended dual applying only for those truly interested in multiple specialties. Eighteen percent (21/115) of respondents advised dual applying for those with less than a 75% chance of matching. Twenty-five percent (29/115) of respondents free-wrote comments about approaching dual applying on a case-by-case basis, with many discussing the downsides of dual application and raising concerns that dual applications can hinder applicants’ success, can seem disingenuous, and seem to be a tool used to improve medical school match rates without benefit for the student.

We also stratified the data to compare overall responses from the total cohort with those from only program and assistant program directors. Across the 14 questions, responses from program and assistant program directors alone were similar to the overall cohort results

Comment

This study evaluated nationwide data on mentorship advising in dermatology, detailing mentors’ advice regarding research, gap years, dual applications, away rotations, intern year, couples matching, program signaling, and volunteering during medical school. Based on our results, most respondents agree on the importance of research during medical school, the utility of away rotations, and the value of volunteering during medical school. Similarly, respondents agreed on the importance of having strong letters of recommendation; while some advised asking only dermatology faculty to write letters, others did not have a specialty preference for the letter writers. Respondents also had varying views about sharing interest in subspecialties during residency interviews. Many of the respondents do not provide recommendations regarding geographic signaling and couples matching, expressing that these are parts of an application that are important to approach on a case-by-case basis. Lastly, respondents had diverse opinions regarding the utility of gap years, whether to encourage or discourage dual applications, and how to advise regarding program signaling.

Our results also showed that one-third of respondents believed that research is not as important as it is perceived to be by dermatology applicants. While engaging in research during medical school was almost unanimously encouraged to foster mentor-mentee relationships, respondents expressed that the number of research experiences and publications was not critical. This is an important topic of discussion, as taking a dedicated year away from medical school to complete a research fellowship is becoming a trend among dermatology applicants.⁵ There has been discussion both on unofficial online platforms as well as in the published literature regarding the pressure for medical students interested in dermatology to publish, which may result in a gap year for research.⁶ The literature on the utility of a gap year in match rates is sparse, with one study showing no difference in match rates among Mayo Clinic dermatology residents who took research years vs those who did not.⁷ However, this contrasts with match rates at top dermatology residency programs where 41% of applicants who took a gap year matched vs 19% who did not.^7,8 These conflicting data are reflected in our study results, with respondents expressing different opinions on the utility of gap years.

There also are important equity concerns regarding the role of research years in the dermatology residency match process. Dermatology is one of the least racially diverse specialties, although there have been efforts to increase representation among residents and attending physicians.^9-11 Research years can be important contributors to this lack of representation, as these often are unpaid and can discourage economically disadvantaged students from applying.^9-11 Additionally, applicants may not have the flexibility to defer future salary for a year to match into dermatology; therefore, mentors should offer multiple options to individual applicants instead of solely encouraging gap years, given the conflicting feelings regarding their productivity.

Another topic of disagreement was dual application. Approximately one-third of respondents said they encourage either all students or those with less than a 75% chance of matching to dual apply, while about half only encourage students who are truly interested in multiple specialties to do so. Additionally, a large subset of respondents said they do not encourage dual applications due to concerns that they make applicants a worse candidate for each specialty and overall have negative effects on matching. Twenty-five percent of respondents opted to leave an open-ended response to this question: some offered the perspective that, if applicants feel a need to dual apply due to a weaker application, they do not advise the applicant to apply to dermatology. Many open ended responses underscored that the respondent does not encourage dual applications because they are inherently more time consuming, could hinder the applicant’s success, can seem disingenuous, and are a tool used to improve medical school match rates without being beneficial for the student. Some respondents also favored reapplying to dermatology the following year instead of dual applying. Finally, a subset of mentors indicated that they approach dual applications on a case-by-case basis, and others reported they do not have much experience advising on this topic. Currently, there are no known data in the literature on the efficacy and utility of dual applications in the dermatology match process; therefore, our study provides valuable insight for applicants interested in the impacts of the dual application. Overall, students should approach this option with mentors on an individual basis but ultimately should be aware of the concerns and mixed perceptions of the dual application process.

With regard to program signaling, previous research has shown that PSTs have a large impact on the chance of being granted an interview.¹² In our study, we provide a comprehensive overview of advising regarding these signals. While mentors often responded that they did not have much experience advising in this domain—and it is too soon to tell the impact of this program signaling—many offered differing opinions. Many said they recommend that students give a gold signal to their 3 most desired programs regardless of home and away rotations and perceived competitiveness, which follows the guidelines issued by the APD; however, 19% recommend only giving silver signals to home and away rotation programs, as participation in those programs is considered a sufficient signal of interest. Additionally, about half of mentors recommended that students only apply where they signal, whereas 20% recommended applying to 10 to 15 programs beyond those signaled. Future studies should investigate the impact of PSTs on interview invitations once sufficient application cycles have occurred.

Study Limitations

This study was conducted via email to the APD listserve. The total number of faculty on this listserve is unknown; therefore, we do not know the total response rate of the survey. Additionally, we surveyed mentors in this listserve, who therefore receive more emails and overall correspondence about the dermatology match and may be more involved in these conversations. The mentors who responded to our survey may have a different approach and response to our various survey questions than a given mentor across the United States who did not respond to this survey. A final limitation of our study is that the survey responses a mentor gives may not fully match the advice that they give their students privately.

Conclusion

Our survey of dermatology mentors across the United States provides valuable insight into how mentors advise for a strong dermatology residency application. Mentors agreed on the importance of research during medical school, away rotations, strong letters of recommendation, and volunteerism and advocacy to promote a strong residency application. Important topics of disagreement include the decision for dermatology applicants to take a dedicated gap year in medical school, how to use tokens/signals effectively, and the dual application process. Our findings also underscore important application components that applicants and mentors should approach on an individual basis. Future studies should investigate the impact of signals/tokens on the match process as well as the utility of gap years and dual applications, working to standardize the advice applicants receive.

While strong relationships with mentors and advisers are critical to navigating the competitive dermatology match process, the advice medical students receive from different individuals can be contradictory. Unaccredited information online—particularly on social media—as well as data reported by applicants can add to potential confusion.¹ Published research has elicited comments and observations from successfully matched medical students about highly discussed topics such as presentations and publications, letters of recommendation, away rotations, and interviews.^2,3 However, there currently are no published data about advice that dermatology mentors actually offer medical students. In this study, we aimed to investigate this gap in the current literature and examine the advice dermatology faculty, program directors, and other mentors at institutions accredited by the Accreditation Council for Graduate Medical Education across the United States give to medical students applying to dermatology residency.

Methods

A 14-question Johns Hopkins Qualtrics survey was sent via the Association of Professors of Dermatology (APD) listserve in June 2024 soliciting responses from members who consider themselves to be mentors to dermatology applicants across the United States. The survey included multiple-choice questions with the option to select multiple answers and a space for open-ended responses. The questions first gathered information on the respondents, including the capacity in which the mentors advised medical students (eg, program director, department chair, clinical faculty). Mentors were asked for the number of years they had been advising mentees and if they were advising students with a home dermatology program. In addition, mentors were asked what advice they give their mentees about aspects of the application process, including gap years, dual applications, research involvement, couples matching, program signaling, away rotations, internship year, letters of recommendation, geographic signaling, interviewing advice, and volunteering during medical school.

On August 18, 2024, survey results from 115 respondents were aggregated. The responses for each question were quantitatively assessed to determine whether there was consensus on specific advice offered. The open-ended responses also were qualitatively assessed to determine the most common responses.

Results

The respondents included program directors (30% [35/115]), clinical faculty (22% [25/115]), department chairs (18% [21/115]), assistant program directors (15% [17/115]), medical school clerkship directors (8% [9/115]), primary mentors (ie, faculty who did not fall into any of the aforementioned categories but still advised medical students interested in dermatology)(5% [6/115]), division chiefs (1% [1/115]), and deans (1% [1/115]). Respondents had been advising students for a median of 10 years (range, 1-40 years [25th percentile, 5.00 years; 75th percentile, 13.75 years]). The majority (90% [103/115]) of mentors surveyed were advising students with a home dermatology program.

Areas of Consensus

In some areas, there was broad consensus among the advice offered by the mentors that were surveyed (eTable).

Research During Medical School—More than 91% (105/115) of the respondents recommended research to encourage academic growth and indicated that the most important reason for conducting research during medical school is to foster mentor-mentee relationships; however, more than one-third of respondents believed research is overvalued by students and research productivity is not as critical for matching as they perceive it to be. When these responses were categorized by respondent positions, 29% (15/52) of program or assistant directors indicated agreement with the statement that research is overvalued.

Away Rotations—There also was a consensus about the importance of away rotations, with 85% (98/115) of respondents advising students to complete 1 to 2 away rotations at sites of high interest, and 13% (15/115) suggesting that students complete as many away rotations as possible. It is worth noting, however, that the official APD Residency Program Directors Section’s statement on away rotations recommends no more than 2 away rotations (or no more than 3 for students with no home program).⁴

Reapplication Advice—Additionally, in a situation where students do not match into a dermatology residency program, the vast majority (71% [82/115]) of respondents advised students to rank competitive intern years to foster connections and improve the chance of matching on the second attempt.

Volunteering During Medical School—Seventy-seven percent (89/115) of mentors encouraged students to engage in volunteerism and advocacy during medical school to create a well-rounded application, and 69% (79/115) of mentors encouraged students to display leadership in their volunteer efforts.

Areas Without Consensus

Letters of Recommendation—Most respondents recommended submitting letters of recommendation only from dermatology professionals (55% [63/115]), with the remainder recommending students request a letter from anyone who could provide a strong recommendation regardless of specialty mix (42% [48/115]).

Dermatologic Subspecialties—For students interested in dermatologic subspecialties, 73% (84/115) of mentors advised that students be honest during interviews but keep an open mind that interests during residencies may change. Forty-three percent (49/115) of respondents encouraged students to promote a subspecialty interest during their interview only if they can demonstrate effort within that subspecialty on their application.

Couples Matching—Most respondents approach couples matching on a case-by-case basis and assess individual priorities when they do advise on this topic. Respondents often advise applicants to identify a few cities/regions and focus strongly on the programs within those regions to avoid spreading themselves too thin; however, one-third (38/115) of respondents indicated that they do not personally offer advice regarding the couples match.

Areas With Diverse Opinions

Gap Years—Nearly one-quarter (24% [28/115]) of mentors reported that they rarely recommend students take a year off and only support those who are adamant about doing so, or that they never support taking a gap year at all. A slight majority (58% [67/115]) recommend a gap year for students strongly interested in dermatologic research, and 38% (44/115) recommend a gap year for students with weaker applications (Figure 1). We received many open-ended responses to this question, with mentors frequently indicating that they advise students to take a gap year on a case-by-case basis, with 44% (51/115) of commenters recommending that students only take paid gap-year research positions.

Program Signaling—The dermatology residency application process implemented a system of preference signaling tokens (PSTs) starting with the 2021-2022 cycle. Not quite half (46% [53/115]) of respondents recommend students apply only to places that they signaled, while 20% (23/115) advise responding to 10 to 15 additional programs. Very few (8% [9/115]) advise students to signal only in their stated region of interest. Approximately half (49% [56/115]) of mentors recommend students only signal based on the programs they feel would be the best fit for them without regard for perceived competitiveness—which aligns with the APD Residency Program Directors Section’s recommendation⁴—while 37% (43/115) recommend students distribute their signals to a wide range of programs. Sixty-three percent (72/115) of respondents recommend gold signaling to the student’s 3 most desired programs regardless of home and away rotation considerations, while 19% (22/115) recommend students give silver signals to their home and away rotation programs, as a rotation is already a signal of a strong desire to be there (Figure 2).

Dual Application—Fifty-three percent (61/115) of mentors recommended dual applying only for those truly interested in multiple specialties. Eighteen percent (21/115) of respondents advised dual applying for those with less than a 75% chance of matching. Twenty-five percent (29/115) of respondents free-wrote comments about approaching dual applying on a case-by-case basis, with many discussing the downsides of dual application and raising concerns that dual applications can hinder applicants’ success, can seem disingenuous, and seem to be a tool used to improve medical school match rates without benefit for the student.

We also stratified the data to compare overall responses from the total cohort with those from only program and assistant program directors. Across the 14 questions, responses from program and assistant program directors alone were similar to the overall cohort results

Comment

This study evaluated nationwide data on mentorship advising in dermatology, detailing mentors’ advice regarding research, gap years, dual applications, away rotations, intern year, couples matching, program signaling, and volunteering during medical school. Based on our results, most respondents agree on the importance of research during medical school, the utility of away rotations, and the value of volunteering during medical school. Similarly, respondents agreed on the importance of having strong letters of recommendation; while some advised asking only dermatology faculty to write letters, others did not have a specialty preference for the letter writers. Respondents also had varying views about sharing interest in subspecialties during residency interviews. Many of the respondents do not provide recommendations regarding geographic signaling and couples matching, expressing that these are parts of an application that are important to approach on a case-by-case basis. Lastly, respondents had diverse opinions regarding the utility of gap years, whether to encourage or discourage dual applications, and how to advise regarding program signaling.

Our results also showed that one-third of respondents believed that research is not as important as it is perceived to be by dermatology applicants. While engaging in research during medical school was almost unanimously encouraged to foster mentor-mentee relationships, respondents expressed that the number of research experiences and publications was not critical. This is an important topic of discussion, as taking a dedicated year away from medical school to complete a research fellowship is becoming a trend among dermatology applicants.⁵ There has been discussion both on unofficial online platforms as well as in the published literature regarding the pressure for medical students interested in dermatology to publish, which may result in a gap year for research.⁶ The literature on the utility of a gap year in match rates is sparse, with one study showing no difference in match rates among Mayo Clinic dermatology residents who took research years vs those who did not.⁷ However, this contrasts with match rates at top dermatology residency programs where 41% of applicants who took a gap year matched vs 19% who did not.^7,8 These conflicting data are reflected in our study results, with respondents expressing different opinions on the utility of gap years.

There also are important equity concerns regarding the role of research years in the dermatology residency match process. Dermatology is one of the least racially diverse specialties, although there have been efforts to increase representation among residents and attending physicians.^9-11 Research years can be important contributors to this lack of representation, as these often are unpaid and can discourage economically disadvantaged students from applying.^9-11 Additionally, applicants may not have the flexibility to defer future salary for a year to match into dermatology; therefore, mentors should offer multiple options to individual applicants instead of solely encouraging gap years, given the conflicting feelings regarding their productivity.

Another topic of disagreement was dual application. Approximately one-third of respondents said they encourage either all students or those with less than a 75% chance of matching to dual apply, while about half only encourage students who are truly interested in multiple specialties to do so. Additionally, a large subset of respondents said they do not encourage dual applications due to concerns that they make applicants a worse candidate for each specialty and overall have negative effects on matching. Twenty-five percent of respondents opted to leave an open-ended response to this question: some offered the perspective that, if applicants feel a need to dual apply due to a weaker application, they do not advise the applicant to apply to dermatology. Many open ended responses underscored that the respondent does not encourage dual applications because they are inherently more time consuming, could hinder the applicant’s success, can seem disingenuous, and are a tool used to improve medical school match rates without being beneficial for the student. Some respondents also favored reapplying to dermatology the following year instead of dual applying. Finally, a subset of mentors indicated that they approach dual applications on a case-by-case basis, and others reported they do not have much experience advising on this topic. Currently, there are no known data in the literature on the efficacy and utility of dual applications in the dermatology match process; therefore, our study provides valuable insight for applicants interested in the impacts of the dual application. Overall, students should approach this option with mentors on an individual basis but ultimately should be aware of the concerns and mixed perceptions of the dual application process.

With regard to program signaling, previous research has shown that PSTs have a large impact on the chance of being granted an interview.¹² In our study, we provide a comprehensive overview of advising regarding these signals. While mentors often responded that they did not have much experience advising in this domain—and it is too soon to tell the impact of this program signaling—many offered differing opinions. Many said they recommend that students give a gold signal to their 3 most desired programs regardless of home and away rotations and perceived competitiveness, which follows the guidelines issued by the APD; however, 19% recommend only giving silver signals to home and away rotation programs, as participation in those programs is considered a sufficient signal of interest. Additionally, about half of mentors recommended that students only apply where they signal, whereas 20% recommended applying to 10 to 15 programs beyond those signaled. Future studies should investigate the impact of PSTs on interview invitations once sufficient application cycles have occurred.

Study Limitations

This study was conducted via email to the APD listserve. The total number of faculty on this listserve is unknown; therefore, we do not know the total response rate of the survey. Additionally, we surveyed mentors in this listserve, who therefore receive more emails and overall correspondence about the dermatology match and may be more involved in these conversations. The mentors who responded to our survey may have a different approach and response to our various survey questions than a given mentor across the United States who did not respond to this survey. A final limitation of our study is that the survey responses a mentor gives may not fully match the advice that they give their students privately.

Conclusion

Our survey of dermatology mentors across the United States provides valuable insight into how mentors advise for a strong dermatology residency application. Mentors agreed on the importance of research during medical school, away rotations, strong letters of recommendation, and volunteerism and advocacy to promote a strong residency application. Important topics of disagreement include the decision for dermatology applicants to take a dedicated gap year in medical school, how to use tokens/signals effectively, and the dual application process. Our findings also underscore important application components that applicants and mentors should approach on an individual basis. Future studies should investigate the impact of signals/tokens on the match process as well as the utility of gap years and dual applications, working to standardize the advice applicants receive.

Most medical students applying to dermatology residency programs in the United States will participate in an away rotation at an outside institution. Prior to COVID-19–related restrictions, 86.7% of dermatology applicants from the class of 2020 reported completing one or more away rotations for their application cycle.^1,2 This requirement can be considerably costly, especially since most programs do not offer financial support for travel, living expenses, or housing during these visiting experiences.³ Underrepresented in medicine (URiM) students may be particularly disadvantaged with regard to the financial obligations that come with away rotations.^4,5 Visiting scholarships for URiM students can mitigate these challenges, creating opportunities for increasing diversity in dermatology. When medical students begin the residency application process, the Visiting Student Learning Opportunities (VSLO) program of the Association of American Medical Colleges (AAMC) is the most widely used third-party service for submitting applications. For many URiM students, an unforeseen challenge when applying to dermatology residency programs is the lack of an easily accessible and up-to-date search tool to find programs that offer funding, resulting in more time spent searching and thereby complicating the application process. The VSLO released the Visiting Scholars Resources Database, a search tool that aims to compile opportunities for additional support—academic professional, and/or financial—to address this issue. Additionally, the Funded Away Rotations for Minority Medical Students (FARMS) database is an independent directory of programs that offer stipends to URiM students. In this study, we evaluated the efficacy of the VLSO’s Visiting Scholars Resources Database search tool and the FARMS database in identifying funded dermatology rotations for URiM students.

Overview of Online Search Tools

We used the AAMC’s Electronic Residency Application Service Directory to identify 141 programs offering dermatology residency positions. We then conducted a Google search using each program name with the phrase underrepresented in medicine dermatology away rotation to identify any opportunities noted in the Google results offering scholarship funding for URiM students. If there were no Google results for a webpage discussing URiM away rotation opportunities for a certain program, the individual program’s website search box was queried using the terms URiM, scholarship, and funding. If there were no relevant results, the webpages associated with the dermatology department, away rotations, and diversity and inclusion on the respective institution’s website were reviewed to confirm no indication of funded URiM opportunities. Of the 141 dermatology programs we evaluated, we identified 56 (39.7%) that offered funded away rotations for URiM students.

For comparison, we conducted a search of the VSLO’s Visiting Scholars Resources Database to identify programs that listed dermatology, all (specialties), or any (specialties) under the Specialty column that also had a financial resource for URiM students. Our search of the VSLO database yielded only 12 (21.4%) of the 56 funded away rotations we identified via our initial Google and program website search. Program listings tagged for dermatology also were retrieved from the FARMS database, of which only 17 (30.4%) of the 56 funded away rotations we previously identified were included. All queries were performed from October 24 to October 26, 2024 (Figure).

Comment

The 2023-2024 AAMC Report on Residents indicated that 54.9% (800/1455) of active US dermatology medical residents identified as White, 27.5% (400/1455) identified as Asian, 8.9% (129/1455) identified as Hispanic, and 8.7% (126/1455) identified as Black or African American.⁶ By comparison, 19.5% of the general US population identifies as Hispanic and 13.7% identifies as Black.⁷ Within the field of dermatology, the proportion of Black dermatology academic faculty in the US is estimated to comprise only 18.7% of all active Black dermatologists.^8,9 With a growing population of minority US citizens, the dermatology workforce is lagging in representation across all minority populations, especially when it comes to Hispanic and Black individuals. To increase the diversity of the US dermatology workforce, residency programs must prioritize recruitment of URiM students and support their retention as future faculty.

Reports in the literature suggest that clinical grades, US Medical Licensing Examination scores, letters of recommendation/ networking, and the risk of not matching are among the primary concerns that URiM students face as potential barriers to applying for dermatology residency.⁴ Meanwhile, dermatology program directors ranked diversity characteristics, perceived interest in the program, personal prior knowledge of an applicant, and audition rotation in their department as important considerations for interviewing applicants.¹⁰ As a result, URiM students may have the diverse characteristics that program directors are looking for, but obtaining away rotations and establishing mentors at other institutions may be challenging due to the burden of accruing additional costs for visiting rotations.^2,10,11 Other reports have indicated that expanding funded dermatology visiting rotations and promoting national programs such as the American Academy of Dermatology Diversity Mentorship Program (https://www.aad.org/member/career/awards/diversity) or the Skin of Color Society Observership Grant (https://skinofcolorsociety.org/what-we-do/mentorship/observership-grant) can be alternative routes for mentorship and networking.³

Our review demonstrated that, of the 141 dermatology residency programs we identified, only around 40% offer funded rotations for URiM students; however, the current databases that applicants use to find these opportunities do not adequately present the number of available options. A search of the VSLO database—the most widely used third-party database for applying to dermatology away rotations—yielded only 12 (21.4%) of the rotations that we identified in our initial Google search. Similarly, a search of the FARMS database yielded only 17 (30.4%) of the dermatology rotations we previously identified. Aside from missing more than half of the available funded dermatology away rotations, the search process was further complicated by the reliance of the 2 databases on user input rather than presenting all programs offering funded opportunities for dermatology applicants without the need to enter additional information. As of October 26, 2024, there were only 22 inputs for Visiting Scholars Resources across all specialties and programs in the VLSO system.

Our findings indicate a clear need for a reliable and accurate database that captures all funded dermatology rotations for prospective URiM applicants because of the strong emphasis on visiting rotations for application success. Our team created a Google spreadsheet compiling dermatology visiting student health equity and inclusion scholarships from inputs we found in our search. We shared this resource via the Association of Professors of Dermatology listserve so program members could verify the opportunities we compiled to create an accurate and updated resource for finding funded dermatology rotations. The program verification process was conducted by having residency program directors or their respective program coordinators mark “yes” on the spreadsheet to confirm the funded rotation is being offered by their program. Our spreadsheet will continue to be updated yearly through cooperation with participating programs to verify their funded electives and through partnership with the AAMC to include our database in their Visiting Students Resources Database that will be released each year within VLSO as applications open for the following season.

The main limitation of our review is that we presume the information provided in the VSLO and FARMS databases has not changed or been updated to include more programs since our initial search period. Additionally, the information available on dermatology residency program websites limits the data on the total programs obtained, as some website links may not be updated or may be invalid for online web user access. The benefit to creating and continually updating our Dermatology Visiting Student Health Equity and Inclusion Scholarship Database spreadsheet will be to ensure that programs regularly verify their offered funded electives and capture the true total of funded rotations offered for URiM students across the country. We also acknowledge that we did not investigate how URiM student attendance at funded rotations affected their outcomes in matching dermatology programs for residency; however, given the importance of away rotations, which positively influence the ability of URiM students to receive interviews, it is understood that these opportunities are viewed as widely beneficial.

Final Thoughts

The current online search tools that URiM students can use to find funded away rotations in dermatology exclude many of the available opportunities. We aimed to provide an updated and centralized resource for students via the shared spreadsheet we created for residency program directors, but further measures to centralize the most up-to-date information on visiting programs offering scholarships to URiM students would be beneficial.

Most medical students applying to dermatology residency programs in the United States will participate in an away rotation at an outside institution. Prior to COVID-19–related restrictions, 86.7% of dermatology applicants from the class of 2020 reported completing one or more away rotations for their application cycle.^1,2 This requirement can be considerably costly, especially since most programs do not offer financial support for travel, living expenses, or housing during these visiting experiences.³ Underrepresented in medicine (URiM) students may be particularly disadvantaged with regard to the financial obligations that come with away rotations.^4,5 Visiting scholarships for URiM students can mitigate these challenges, creating opportunities for increasing diversity in dermatology. When medical students begin the residency application process, the Visiting Student Learning Opportunities (VSLO) program of the Association of American Medical Colleges (AAMC) is the most widely used third-party service for submitting applications. For many URiM students, an unforeseen challenge when applying to dermatology residency programs is the lack of an easily accessible and up-to-date search tool to find programs that offer funding, resulting in more time spent searching and thereby complicating the application process. The VSLO released the Visiting Scholars Resources Database, a search tool that aims to compile opportunities for additional support—academic professional, and/or financial—to address this issue. Additionally, the Funded Away Rotations for Minority Medical Students (FARMS) database is an independent directory of programs that offer stipends to URiM students. In this study, we evaluated the efficacy of the VLSO’s Visiting Scholars Resources Database search tool and the FARMS database in identifying funded dermatology rotations for URiM students.

Overview of Online Search Tools

We used the AAMC’s Electronic Residency Application Service Directory to identify 141 programs offering dermatology residency positions. We then conducted a Google search using each program name with the phrase underrepresented in medicine dermatology away rotation to identify any opportunities noted in the Google results offering scholarship funding for URiM students. If there were no Google results for a webpage discussing URiM away rotation opportunities for a certain program, the individual program’s website search box was queried using the terms URiM, scholarship, and funding. If there were no relevant results, the webpages associated with the dermatology department, away rotations, and diversity and inclusion on the respective institution’s website were reviewed to confirm no indication of funded URiM opportunities. Of the 141 dermatology programs we evaluated, we identified 56 (39.7%) that offered funded away rotations for URiM students.

For comparison, we conducted a search of the VSLO’s Visiting Scholars Resources Database to identify programs that listed dermatology, all (specialties), or any (specialties) under the Specialty column that also had a financial resource for URiM students. Our search of the VSLO database yielded only 12 (21.4%) of the 56 funded away rotations we identified via our initial Google and program website search. Program listings tagged for dermatology also were retrieved from the FARMS database, of which only 17 (30.4%) of the 56 funded away rotations we previously identified were included. All queries were performed from October 24 to October 26, 2024 (Figure).

Comment

The 2023-2024 AAMC Report on Residents indicated that 54.9% (800/1455) of active US dermatology medical residents identified as White, 27.5% (400/1455) identified as Asian, 8.9% (129/1455) identified as Hispanic, and 8.7% (126/1455) identified as Black or African American.⁶ By comparison, 19.5% of the general US population identifies as Hispanic and 13.7% identifies as Black.⁷ Within the field of dermatology, the proportion of Black dermatology academic faculty in the US is estimated to comprise only 18.7% of all active Black dermatologists.^8,9 With a growing population of minority US citizens, the dermatology workforce is lagging in representation across all minority populations, especially when it comes to Hispanic and Black individuals. To increase the diversity of the US dermatology workforce, residency programs must prioritize recruitment of URiM students and support their retention as future faculty.

Reports in the literature suggest that clinical grades, US Medical Licensing Examination scores, letters of recommendation/ networking, and the risk of not matching are among the primary concerns that URiM students face as potential barriers to applying for dermatology residency.⁴ Meanwhile, dermatology program directors ranked diversity characteristics, perceived interest in the program, personal prior knowledge of an applicant, and audition rotation in their department as important considerations for interviewing applicants.¹⁰ As a result, URiM students may have the diverse characteristics that program directors are looking for, but obtaining away rotations and establishing mentors at other institutions may be challenging due to the burden of accruing additional costs for visiting rotations.^2,10,11 Other reports have indicated that expanding funded dermatology visiting rotations and promoting national programs such as the American Academy of Dermatology Diversity Mentorship Program (https://www.aad.org/member/career/awards/diversity) or the Skin of Color Society Observership Grant (https://skinofcolorsociety.org/what-we-do/mentorship/observership-grant) can be alternative routes for mentorship and networking.³

Our review demonstrated that, of the 141 dermatology residency programs we identified, only around 40% offer funded rotations for URiM students; however, the current databases that applicants use to find these opportunities do not adequately present the number of available options. A search of the VSLO database—the most widely used third-party database for applying to dermatology away rotations—yielded only 12 (21.4%) of the rotations that we identified in our initial Google search. Similarly, a search of the FARMS database yielded only 17 (30.4%) of the dermatology rotations we previously identified. Aside from missing more than half of the available funded dermatology away rotations, the search process was further complicated by the reliance of the 2 databases on user input rather than presenting all programs offering funded opportunities for dermatology applicants without the need to enter additional information. As of October 26, 2024, there were only 22 inputs for Visiting Scholars Resources across all specialties and programs in the VLSO system.

Our findings indicate a clear need for a reliable and accurate database that captures all funded dermatology rotations for prospective URiM applicants because of the strong emphasis on visiting rotations for application success. Our team created a Google spreadsheet compiling dermatology visiting student health equity and inclusion scholarships from inputs we found in our search. We shared this resource via the Association of Professors of Dermatology listserve so program members could verify the opportunities we compiled to create an accurate and updated resource for finding funded dermatology rotations. The program verification process was conducted by having residency program directors or their respective program coordinators mark “yes” on the spreadsheet to confirm the funded rotation is being offered by their program. Our spreadsheet will continue to be updated yearly through cooperation with participating programs to verify their funded electives and through partnership with the AAMC to include our database in their Visiting Students Resources Database that will be released each year within VLSO as applications open for the following season.

The main limitation of our review is that we presume the information provided in the VSLO and FARMS databases has not changed or been updated to include more programs since our initial search period. Additionally, the information available on dermatology residency program websites limits the data on the total programs obtained, as some website links may not be updated or may be invalid for online web user access. The benefit to creating and continually updating our Dermatology Visiting Student Health Equity and Inclusion Scholarship Database spreadsheet will be to ensure that programs regularly verify their offered funded electives and capture the true total of funded rotations offered for URiM students across the country. We also acknowledge that we did not investigate how URiM student attendance at funded rotations affected their outcomes in matching dermatology programs for residency; however, given the importance of away rotations, which positively influence the ability of URiM students to receive interviews, it is understood that these opportunities are viewed as widely beneficial.

Final Thoughts

The current online search tools that URiM students can use to find funded away rotations in dermatology exclude many of the available opportunities. We aimed to provide an updated and centralized resource for students via the shared spreadsheet we created for residency program directors, but further measures to centralize the most up-to-date information on visiting programs offering scholarships to URiM students would be beneficial.

Most medical students applying to dermatology residency programs in the United States will participate in an away rotation at an outside institution. Prior to COVID-19–related restrictions, 86.7% of dermatology applicants from the class of 2020 reported completing one or more away rotations for their application cycle.^1,2 This requirement can be considerably costly, especially since most programs do not offer financial support for travel, living expenses, or housing during these visiting experiences.³ Underrepresented in medicine (URiM) students may be particularly disadvantaged with regard to the financial obligations that come with away rotations.^4,5 Visiting scholarships for URiM students can mitigate these challenges, creating opportunities for increasing diversity in dermatology. When medical students begin the residency application process, the Visiting Student Learning Opportunities (VSLO) program of the Association of American Medical Colleges (AAMC) is the most widely used third-party service for submitting applications. For many URiM students, an unforeseen challenge when applying to dermatology residency programs is the lack of an easily accessible and up-to-date search tool to find programs that offer funding, resulting in more time spent searching and thereby complicating the application process. The VSLO released the Visiting Scholars Resources Database, a search tool that aims to compile opportunities for additional support—academic professional, and/or financial—to address this issue. Additionally, the Funded Away Rotations for Minority Medical Students (FARMS) database is an independent directory of programs that offer stipends to URiM students. In this study, we evaluated the efficacy of the VLSO’s Visiting Scholars Resources Database search tool and the FARMS database in identifying funded dermatology rotations for URiM students.

Overview of Online Search Tools

We used the AAMC’s Electronic Residency Application Service Directory to identify 141 programs offering dermatology residency positions. We then conducted a Google search using each program name with the phrase underrepresented in medicine dermatology away rotation to identify any opportunities noted in the Google results offering scholarship funding for URiM students. If there were no Google results for a webpage discussing URiM away rotation opportunities for a certain program, the individual program’s website search box was queried using the terms URiM, scholarship, and funding. If there were no relevant results, the webpages associated with the dermatology department, away rotations, and diversity and inclusion on the respective institution’s website were reviewed to confirm no indication of funded URiM opportunities. Of the 141 dermatology programs we evaluated, we identified 56 (39.7%) that offered funded away rotations for URiM students.

For comparison, we conducted a search of the VSLO’s Visiting Scholars Resources Database to identify programs that listed dermatology, all (specialties), or any (specialties) under the Specialty column that also had a financial resource for URiM students. Our search of the VSLO database yielded only 12 (21.4%) of the 56 funded away rotations we identified via our initial Google and program website search. Program listings tagged for dermatology also were retrieved from the FARMS database, of which only 17 (30.4%) of the 56 funded away rotations we previously identified were included. All queries were performed from October 24 to October 26, 2024 (Figure).

Comment

The 2023-2024 AAMC Report on Residents indicated that 54.9% (800/1455) of active US dermatology medical residents identified as White, 27.5% (400/1455) identified as Asian, 8.9% (129/1455) identified as Hispanic, and 8.7% (126/1455) identified as Black or African American.⁶ By comparison, 19.5% of the general US population identifies as Hispanic and 13.7% identifies as Black.⁷ Within the field of dermatology, the proportion of Black dermatology academic faculty in the US is estimated to comprise only 18.7% of all active Black dermatologists.^8,9 With a growing population of minority US citizens, the dermatology workforce is lagging in representation across all minority populations, especially when it comes to Hispanic and Black individuals. To increase the diversity of the US dermatology workforce, residency programs must prioritize recruitment of URiM students and support their retention as future faculty.

Reports in the literature suggest that clinical grades, US Medical Licensing Examination scores, letters of recommendation/ networking, and the risk of not matching are among the primary concerns that URiM students face as potential barriers to applying for dermatology residency.⁴ Meanwhile, dermatology program directors ranked diversity characteristics, perceived interest in the program, personal prior knowledge of an applicant, and audition rotation in their department as important considerations for interviewing applicants.¹⁰ As a result, URiM students may have the diverse characteristics that program directors are looking for, but obtaining away rotations and establishing mentors at other institutions may be challenging due to the burden of accruing additional costs for visiting rotations.^2,10,11 Other reports have indicated that expanding funded dermatology visiting rotations and promoting national programs such as the American Academy of Dermatology Diversity Mentorship Program (https://www.aad.org/member/career/awards/diversity) or the Skin of Color Society Observership Grant (https://skinofcolorsociety.org/what-we-do/mentorship/observership-grant) can be alternative routes for mentorship and networking.³

Our review demonstrated that, of the 141 dermatology residency programs we identified, only around 40% offer funded rotations for URiM students; however, the current databases that applicants use to find these opportunities do not adequately present the number of available options. A search of the VSLO database—the most widely used third-party database for applying to dermatology away rotations—yielded only 12 (21.4%) of the rotations that we identified in our initial Google search. Similarly, a search of the FARMS database yielded only 17 (30.4%) of the dermatology rotations we previously identified. Aside from missing more than half of the available funded dermatology away rotations, the search process was further complicated by the reliance of the 2 databases on user input rather than presenting all programs offering funded opportunities for dermatology applicants without the need to enter additional information. As of October 26, 2024, there were only 22 inputs for Visiting Scholars Resources across all specialties and programs in the VLSO system.

Our findings indicate a clear need for a reliable and accurate database that captures all funded dermatology rotations for prospective URiM applicants because of the strong emphasis on visiting rotations for application success. Our team created a Google spreadsheet compiling dermatology visiting student health equity and inclusion scholarships from inputs we found in our search. We shared this resource via the Association of Professors of Dermatology listserve so program members could verify the opportunities we compiled to create an accurate and updated resource for finding funded dermatology rotations. The program verification process was conducted by having residency program directors or their respective program coordinators mark “yes” on the spreadsheet to confirm the funded rotation is being offered by their program. Our spreadsheet will continue to be updated yearly through cooperation with participating programs to verify their funded electives and through partnership with the AAMC to include our database in their Visiting Students Resources Database that will be released each year within VLSO as applications open for the following season.

The main limitation of our review is that we presume the information provided in the VSLO and FARMS databases has not changed or been updated to include more programs since our initial search period. Additionally, the information available on dermatology residency program websites limits the data on the total programs obtained, as some website links may not be updated or may be invalid for online web user access. The benefit to creating and continually updating our Dermatology Visiting Student Health Equity and Inclusion Scholarship Database spreadsheet will be to ensure that programs regularly verify their offered funded electives and capture the true total of funded rotations offered for URiM students across the country. We also acknowledge that we did not investigate how URiM student attendance at funded rotations affected their outcomes in matching dermatology programs for residency; however, given the importance of away rotations, which positively influence the ability of URiM students to receive interviews, it is understood that these opportunities are viewed as widely beneficial.

Final Thoughts

The current online search tools that URiM students can use to find funded away rotations in dermatology exclude many of the available opportunities. We aimed to provide an updated and centralized resource for students via the shared spreadsheet we created for residency program directors, but further measures to centralize the most up-to-date information on visiting programs offering scholarships to URiM students would be beneficial.

Dermatopathology education, which comprises approximately 30% of the dermatology residency curriculum, is crucial for the holistic training of dermatology residents to diagnose and manage a range of dermatologic conditions.¹ Additionally, dermatopathology is the topic of one of the 4 American Board of Dermatology CORE Exam modules, further highlighting the need for comprehensive education in this area. A variety of resources including virtual dermatopathology and conventional microscopy training currently are used in residency programs for dermatopathology education.^2,3 Although used less frequently, social media platforms such as Instagram also are used to aid in dermatopathology education for a wider audience.⁴ Other online resources, including the American Society of Dermatopathology website (www.asdp.org) and DermpathAtlas.com, are excellent tools for medical students, residents, and fellows to develop their knowledge.⁵ While these resources are accessible, they must be directly sought out by the student and utilized on their own time. Additionally, if medical students do not have a strong understanding of the basics of dermatopathology, they may not have the foundation required to benefit from these resources.

Dermatopathology education is critical for the overall practice of dermatology, yet most dermatology residency programs may not be incorporating dermatopathology education early enough in training. One study evaluating the timing and length of dermatopathology education during residency reported that fewer than 40% (20/51) of dermatology residency programs allocate 3 or more weeks to dermatopathology education during the second postgraduate year.¹ Despite Ackerman6 advocating for early dermatopathology exposure to best prepare medical students to recognize and manage certain dermatologic conditions, the majority of exposure still seems to occur during postgraduate year 4.¹ Furthermore, current primary care residents feel that their medical school training did not sufficiently prepare them to diagnose and manage dermatologic conditions, with only 37% (93/252) reporting feeling adequately prepared.^7,8 Medical students also reported a lack of confidence in overall dermatology knowledge, with 89% (72/81) reporting they felt neutral, slightly confident, or not at all confident when asked to diagnose skin lesions.⁹ In the same study, the average score was 46.6% (7/15 questions answered correctly) when 74 participants were assessed via a multiple choice quiz on dermatologic diagnosis and treatment, further demonstrating the lack of general dermatology comfort among medical students.⁹ This likely stems from limited dermatology curriculum in medical schools, demonstrating the need for further dermatology education as a whole in medical school.¹⁰

Ensuring robust dermatopathology education in medical school and the first year of dermatology residency has the potential to better prepare medical students for the transition into dermatology residency and clinical practice. We created an introductory dermatopathology lecture and presented it to medical students and first year dermatology residents to improve dermatopathology knowledge and confidence in learners early in their dermatology training.

Structure of the Lecture

Participants included first-year dermatology residents and fourth-year medical students rotating with the Wayne State University Department of Dermatology (Detroit, Michigan). The same facilitator (H.O.) taught each of the lectures, and all lectures were conducted via Zoom at the beginning of the month from May 2024 through November 2024. A total of 7 lectures were given. The lecture was formatted so that a histologic image was shown, then learners expressed their thoughts about what the image was showing before the answer was given. This format allowed participants to view the images on their own device screen and allowed the facilitator to annotate the images. The lecture was divided into 3 sections: (1) cell types and basic structures, (2) anatomic slides, and (3) common diagnoses. Each session lasted approximately 45 minutes.

Section 1: Cell Types and Basic Structures—The first section covered the fundamental cell types (neutrophils, lymphocytes, plasma cells, melanocytes, and eosinophils) along with glandular structures (apocrine, eccrine, and sebaceous). The session was designed to follow a retention and allow learners to think through each slide. First, participants were shown histologic images of each cell type and were asked to identify what type of cell was being shown. On the following slide, key features of each cell type were highlighted. Next, participants similarly were shown images of the glandular structures followed by key features of each. The section concluded with a review of the layers of the skin (stratum corneum, stratum granulosum, stratum lucidum, stratum spinosum, and stratum basale). A histologic image was shown, and the facilitator discussed how to distinguish the layers.

Section 2: Anatomic Sites—This section focused on key pathologic features for differentiating body surfaces, including the scalp, face, eyelids, ears, areolae, palms and soles, and mucosae. Participants initially were shown an image of a hematoxylin and eosin–stained slide from a specific body surface and then were asked to identify structures that may serve as a clue to the anatomic location. If the participants were not sure, they were given hints; for example, when participants were shown an image of the ear and were unsure of the location, the facilitator circled cartilage and asked them to identify the structure. In most cases, once participants named this structure, they were able to recognize that the location was the ear.

Section 3: Common Diagnoses—This section addressed frequently encountered diagnoses in dermatopathology, including basal cell carcinoma, squamous cell carcinoma, squamous cell carcinoma in situ, epidermoid cyst, pilar cyst, seborrheic keratosis, solar lentigo, melanocytic nevus, melanoma, verruca vulgaris, spongiotic dermatitis, psoriasis, and lichen planus. It followed the same format of the first section: participants were shown an hemotoxyllin and eosin–stained image and then were asked to discuss what the diagnosis could be and why. Hints were given if participants struggled to come up with the correct diagnosis. A few slides also were dedicated to distinguishing benign nevi, dysplastic nevi, and melanoma.

Pretest and Posttest Results

Residents participated in the lecture as part of their first-year orientation, and medical students participated during their dermatology rotation. All participants were invited to complete a pretest and a posttest before and after the lecture, respectively. Both assessments were optional and anonymous. The pretest was completed electronically and consisted of 10 knowledge-based, multiple-choice questions that included a histopathologic image and asked, “What is the most likely diagnosis?,” “What is the predominant cell type?,” and “Where was this specimen taken from?” In addition to the knowledge-based questions, participants also were asked to rate their confidence in dermatopathology on a 5-point Likert scale ranging from 1 (not confident at all) to 5 (extremely confident). Participants completed the entire pretest before any information on the topic was provided. After the lecture, participants were asked to complete a posttest identical to the pretest and to rate their confidence in dermatopathology again on the same scale. The posttest included an additional question asking participants to rate the helpfulness of the lecture on a Likert scale ranging from 1 (not helpful at all) to 5 (extremely helpful). Participants completed the posttest within 48 hours of the lecture.

Overall, 15 learners participated in the pretest and 12 in the posttest. Of the 15 pretest participants, 3 were first-year residents and 12 were medical students. Similarly, in the posttest, 2 respondents were first-year residents and 10 were medical students. All responses contained complete pretests and posttests. The mean score on the pretest was 62%, whereas the mean score on the posttest was 75%. A paired t test indicated a statistically significant improvement (P=.017). In addition, the mean rating for confidence in dermatopathology knowledge before the lecture was 1.5 prior to the lecture and 2.6 after the lecture. A paired t test demonstrated statistical significance (P=.010). The mean rating of the helpfulness of the lecture was 4.67. The majority (91.7% [11/12]) of the participants gave a rating of 4 or 5.

Impact of the Lecture on Dermatopathology Knowledge

There is a gap in dermatopathology education early in medical training. Our introductory lecture led to higher post test scores and increased confidence in dermatopathology among medical students and dermatology residents, demonstrating the effectiveness of this kind of program in bridging this education gap. The majority of participants in our lecture said they found the session helpful. A previously published article called for early implementation of dermatology education as a whole in the medical curriculum due to lack of knowledge and confidence, and our introductory lecture may help to bridge this gap.⁸ Increasing dermatopathology content for medical students and first-year dermatology residents can expand knowledge, as shown by the increased scores on the posttest, and better supports learners transitioning to dermatology residency, where dermatopathology constitutes a large part of the overall curriculum.² More comprehensive knowledge of dermatopathology early in dermatology training also may help to better prepare residents to accurately diagnose and manage dermatologic conditions.

Pretest scores showed that the average confidence rating in dermatopathology among participants in our lecture was 1.5, which is rather low. This is consistent with prior studies that have found that residents feel that medical school inadequately prepared them for dermatology residency.^7,8 More than 87% (71/81) of medical students surveyed felt they received inadequate general dermatology training in medical school.⁹ This supports the proposed educational gap that is impacting confidence in overall dermatology knowledge, which includes dermatopathology. In our study, the average confidence rating increased by 1.1 points after the lecture, which was statistically significant (P=.010) and demonstrates that an introductory lecture serves as a feasible intervention to improve confidence in this area.

The feedback we received from participants in our lecture shows the benefits of an introductory interactive lecture with virtual dermatopathology images. Ngo et al2 highlighted how residents perceive virtual images to be superior to conventional microscopy for dermatopathology, which we utilized in our lecture. This method is not only cost effective but also provides a simple way for learners and facilitators to point out key findings on histopathology slides.²

Final Thoughts

Overall, implementing dermatopathology education early in training has a measurable impact on dermatopathology knowledge and confidence among medical students and first-year dermatology residents. An interactive lecture with virtual images similar to the one we describe here may better prepare learners for the transition to dermatology residency by addressing the educational gap in dermatopathology early in training.

Dermatopathology education, which comprises approximately 30% of the dermatology residency curriculum, is crucial for the holistic training of dermatology residents to diagnose and manage a range of dermatologic conditions.¹ Additionally, dermatopathology is the topic of one of the 4 American Board of Dermatology CORE Exam modules, further highlighting the need for comprehensive education in this area. A variety of resources including virtual dermatopathology and conventional microscopy training currently are used in residency programs for dermatopathology education.^2,3 Although used less frequently, social media platforms such as Instagram also are used to aid in dermatopathology education for a wider audience.⁴ Other online resources, including the American Society of Dermatopathology website (www.asdp.org) and DermpathAtlas.com, are excellent tools for medical students, residents, and fellows to develop their knowledge.⁵ While these resources are accessible, they must be directly sought out by the student and utilized on their own time. Additionally, if medical students do not have a strong understanding of the basics of dermatopathology, they may not have the foundation required to benefit from these resources.

Dermatopathology education is critical for the overall practice of dermatology, yet most dermatology residency programs may not be incorporating dermatopathology education early enough in training. One study evaluating the timing and length of dermatopathology education during residency reported that fewer than 40% (20/51) of dermatology residency programs allocate 3 or more weeks to dermatopathology education during the second postgraduate year.¹ Despite Ackerman6 advocating for early dermatopathology exposure to best prepare medical students to recognize and manage certain dermatologic conditions, the majority of exposure still seems to occur during postgraduate year 4.¹ Furthermore, current primary care residents feel that their medical school training did not sufficiently prepare them to diagnose and manage dermatologic conditions, with only 37% (93/252) reporting feeling adequately prepared.^7,8 Medical students also reported a lack of confidence in overall dermatology knowledge, with 89% (72/81) reporting they felt neutral, slightly confident, or not at all confident when asked to diagnose skin lesions.⁹ In the same study, the average score was 46.6% (7/15 questions answered correctly) when 74 participants were assessed via a multiple choice quiz on dermatologic diagnosis and treatment, further demonstrating the lack of general dermatology comfort among medical students.⁹ This likely stems from limited dermatology curriculum in medical schools, demonstrating the need for further dermatology education as a whole in medical school.¹⁰

Ensuring robust dermatopathology education in medical school and the first year of dermatology residency has the potential to better prepare medical students for the transition into dermatology residency and clinical practice. We created an introductory dermatopathology lecture and presented it to medical students and first year dermatology residents to improve dermatopathology knowledge and confidence in learners early in their dermatology training.

Structure of the Lecture

Participants included first-year dermatology residents and fourth-year medical students rotating with the Wayne State University Department of Dermatology (Detroit, Michigan). The same facilitator (H.O.) taught each of the lectures, and all lectures were conducted via Zoom at the beginning of the month from May 2024 through November 2024. A total of 7 lectures were given. The lecture was formatted so that a histologic image was shown, then learners expressed their thoughts about what the image was showing before the answer was given. This format allowed participants to view the images on their own device screen and allowed the facilitator to annotate the images. The lecture was divided into 3 sections: (1) cell types and basic structures, (2) anatomic slides, and (3) common diagnoses. Each session lasted approximately 45 minutes.

Section 1: Cell Types and Basic Structures—The first section covered the fundamental cell types (neutrophils, lymphocytes, plasma cells, melanocytes, and eosinophils) along with glandular structures (apocrine, eccrine, and sebaceous). The session was designed to follow a retention and allow learners to think through each slide. First, participants were shown histologic images of each cell type and were asked to identify what type of cell was being shown. On the following slide, key features of each cell type were highlighted. Next, participants similarly were shown images of the glandular structures followed by key features of each. The section concluded with a review of the layers of the skin (stratum corneum, stratum granulosum, stratum lucidum, stratum spinosum, and stratum basale). A histologic image was shown, and the facilitator discussed how to distinguish the layers.

Section 2: Anatomic Sites—This section focused on key pathologic features for differentiating body surfaces, including the scalp, face, eyelids, ears, areolae, palms and soles, and mucosae. Participants initially were shown an image of a hematoxylin and eosin–stained slide from a specific body surface and then were asked to identify structures that may serve as a clue to the anatomic location. If the participants were not sure, they were given hints; for example, when participants were shown an image of the ear and were unsure of the location, the facilitator circled cartilage and asked them to identify the structure. In most cases, once participants named this structure, they were able to recognize that the location was the ear.

Section 3: Common Diagnoses—This section addressed frequently encountered diagnoses in dermatopathology, including basal cell carcinoma, squamous cell carcinoma, squamous cell carcinoma in situ, epidermoid cyst, pilar cyst, seborrheic keratosis, solar lentigo, melanocytic nevus, melanoma, verruca vulgaris, spongiotic dermatitis, psoriasis, and lichen planus. It followed the same format of the first section: participants were shown an hemotoxyllin and eosin–stained image and then were asked to discuss what the diagnosis could be and why. Hints were given if participants struggled to come up with the correct diagnosis. A few slides also were dedicated to distinguishing benign nevi, dysplastic nevi, and melanoma.

Pretest and Posttest Results

Residents participated in the lecture as part of their first-year orientation, and medical students participated during their dermatology rotation. All participants were invited to complete a pretest and a posttest before and after the lecture, respectively. Both assessments were optional and anonymous. The pretest was completed electronically and consisted of 10 knowledge-based, multiple-choice questions that included a histopathologic image and asked, “What is the most likely diagnosis?,” “What is the predominant cell type?,” and “Where was this specimen taken from?” In addition to the knowledge-based questions, participants also were asked to rate their confidence in dermatopathology on a 5-point Likert scale ranging from 1 (not confident at all) to 5 (extremely confident). Participants completed the entire pretest before any information on the topic was provided. After the lecture, participants were asked to complete a posttest identical to the pretest and to rate their confidence in dermatopathology again on the same scale. The posttest included an additional question asking participants to rate the helpfulness of the lecture on a Likert scale ranging from 1 (not helpful at all) to 5 (extremely helpful). Participants completed the posttest within 48 hours of the lecture.

Overall, 15 learners participated in the pretest and 12 in the posttest. Of the 15 pretest participants, 3 were first-year residents and 12 were medical students. Similarly, in the posttest, 2 respondents were first-year residents and 10 were medical students. All responses contained complete pretests and posttests. The mean score on the pretest was 62%, whereas the mean score on the posttest was 75%. A paired t test indicated a statistically significant improvement (P=.017). In addition, the mean rating for confidence in dermatopathology knowledge before the lecture was 1.5 prior to the lecture and 2.6 after the lecture. A paired t test demonstrated statistical significance (P=.010). The mean rating of the helpfulness of the lecture was 4.67. The majority (91.7% [11/12]) of the participants gave a rating of 4 or 5.

Impact of the Lecture on Dermatopathology Knowledge

There is a gap in dermatopathology education early in medical training. Our introductory lecture led to higher post test scores and increased confidence in dermatopathology among medical students and dermatology residents, demonstrating the effectiveness of this kind of program in bridging this education gap. The majority of participants in our lecture said they found the session helpful. A previously published article called for early implementation of dermatology education as a whole in the medical curriculum due to lack of knowledge and confidence, and our introductory lecture may help to bridge this gap.⁸ Increasing dermatopathology content for medical students and first-year dermatology residents can expand knowledge, as shown by the increased scores on the posttest, and better supports learners transitioning to dermatology residency, where dermatopathology constitutes a large part of the overall curriculum.² More comprehensive knowledge of dermatopathology early in dermatology training also may help to better prepare residents to accurately diagnose and manage dermatologic conditions.

Pretest scores showed that the average confidence rating in dermatopathology among participants in our lecture was 1.5, which is rather low. This is consistent with prior studies that have found that residents feel that medical school inadequately prepared them for dermatology residency.^7,8 More than 87% (71/81) of medical students surveyed felt they received inadequate general dermatology training in medical school.⁹ This supports the proposed educational gap that is impacting confidence in overall dermatology knowledge, which includes dermatopathology. In our study, the average confidence rating increased by 1.1 points after the lecture, which was statistically significant (P=.010) and demonstrates that an introductory lecture serves as a feasible intervention to improve confidence in this area.

The feedback we received from participants in our lecture shows the benefits of an introductory interactive lecture with virtual dermatopathology images. Ngo et al2 highlighted how residents perceive virtual images to be superior to conventional microscopy for dermatopathology, which we utilized in our lecture. This method is not only cost effective but also provides a simple way for learners and facilitators to point out key findings on histopathology slides.²

Final Thoughts

Overall, implementing dermatopathology education early in training has a measurable impact on dermatopathology knowledge and confidence among medical students and first-year dermatology residents. An interactive lecture with virtual images similar to the one we describe here may better prepare learners for the transition to dermatology residency by addressing the educational gap in dermatopathology early in training.

Dermatopathology education, which comprises approximately 30% of the dermatology residency curriculum, is crucial for the holistic training of dermatology residents to diagnose and manage a range of dermatologic conditions.¹ Additionally, dermatopathology is the topic of one of the 4 American Board of Dermatology CORE Exam modules, further highlighting the need for comprehensive education in this area. A variety of resources including virtual dermatopathology and conventional microscopy training currently are used in residency programs for dermatopathology education.^2,3 Although used less frequently, social media platforms such as Instagram also are used to aid in dermatopathology education for a wider audience.⁴ Other online resources, including the American Society of Dermatopathology website (www.asdp.org) and DermpathAtlas.com, are excellent tools for medical students, residents, and fellows to develop their knowledge.⁵ While these resources are accessible, they must be directly sought out by the student and utilized on their own time. Additionally, if medical students do not have a strong understanding of the basics of dermatopathology, they may not have the foundation required to benefit from these resources.

Dermatopathology education is critical for the overall practice of dermatology, yet most dermatology residency programs may not be incorporating dermatopathology education early enough in training. One study evaluating the timing and length of dermatopathology education during residency reported that fewer than 40% (20/51) of dermatology residency programs allocate 3 or more weeks to dermatopathology education during the second postgraduate year.¹ Despite Ackerman6 advocating for early dermatopathology exposure to best prepare medical students to recognize and manage certain dermatologic conditions, the majority of exposure still seems to occur during postgraduate year 4.¹ Furthermore, current primary care residents feel that their medical school training did not sufficiently prepare them to diagnose and manage dermatologic conditions, with only 37% (93/252) reporting feeling adequately prepared.^7,8 Medical students also reported a lack of confidence in overall dermatology knowledge, with 89% (72/81) reporting they felt neutral, slightly confident, or not at all confident when asked to diagnose skin lesions.⁹ In the same study, the average score was 46.6% (7/15 questions answered correctly) when 74 participants were assessed via a multiple choice quiz on dermatologic diagnosis and treatment, further demonstrating the lack of general dermatology comfort among medical students.⁹ This likely stems from limited dermatology curriculum in medical schools, demonstrating the need for further dermatology education as a whole in medical school.¹⁰

Ensuring robust dermatopathology education in medical school and the first year of dermatology residency has the potential to better prepare medical students for the transition into dermatology residency and clinical practice. We created an introductory dermatopathology lecture and presented it to medical students and first year dermatology residents to improve dermatopathology knowledge and confidence in learners early in their dermatology training.

Structure of the Lecture

Participants included first-year dermatology residents and fourth-year medical students rotating with the Wayne State University Department of Dermatology (Detroit, Michigan). The same facilitator (H.O.) taught each of the lectures, and all lectures were conducted via Zoom at the beginning of the month from May 2024 through November 2024. A total of 7 lectures were given. The lecture was formatted so that a histologic image was shown, then learners expressed their thoughts about what the image was showing before the answer was given. This format allowed participants to view the images on their own device screen and allowed the facilitator to annotate the images. The lecture was divided into 3 sections: (1) cell types and basic structures, (2) anatomic slides, and (3) common diagnoses. Each session lasted approximately 45 minutes.

Section 1: Cell Types and Basic Structures—The first section covered the fundamental cell types (neutrophils, lymphocytes, plasma cells, melanocytes, and eosinophils) along with glandular structures (apocrine, eccrine, and sebaceous). The session was designed to follow a retention and allow learners to think through each slide. First, participants were shown histologic images of each cell type and were asked to identify what type of cell was being shown. On the following slide, key features of each cell type were highlighted. Next, participants similarly were shown images of the glandular structures followed by key features of each. The section concluded with a review of the layers of the skin (stratum corneum, stratum granulosum, stratum lucidum, stratum spinosum, and stratum basale). A histologic image was shown, and the facilitator discussed how to distinguish the layers.

Section 2: Anatomic Sites—This section focused on key pathologic features for differentiating body surfaces, including the scalp, face, eyelids, ears, areolae, palms and soles, and mucosae. Participants initially were shown an image of a hematoxylin and eosin–stained slide from a specific body surface and then were asked to identify structures that may serve as a clue to the anatomic location. If the participants were not sure, they were given hints; for example, when participants were shown an image of the ear and were unsure of the location, the facilitator circled cartilage and asked them to identify the structure. In most cases, once participants named this structure, they were able to recognize that the location was the ear.

Section 3: Common Diagnoses—This section addressed frequently encountered diagnoses in dermatopathology, including basal cell carcinoma, squamous cell carcinoma, squamous cell carcinoma in situ, epidermoid cyst, pilar cyst, seborrheic keratosis, solar lentigo, melanocytic nevus, melanoma, verruca vulgaris, spongiotic dermatitis, psoriasis, and lichen planus. It followed the same format of the first section: participants were shown an hemotoxyllin and eosin–stained image and then were asked to discuss what the diagnosis could be and why. Hints were given if participants struggled to come up with the correct diagnosis. A few slides also were dedicated to distinguishing benign nevi, dysplastic nevi, and melanoma.

Pretest and Posttest Results

Residents participated in the lecture as part of their first-year orientation, and medical students participated during their dermatology rotation. All participants were invited to complete a pretest and a posttest before and after the lecture, respectively. Both assessments were optional and anonymous. The pretest was completed electronically and consisted of 10 knowledge-based, multiple-choice questions that included a histopathologic image and asked, “What is the most likely diagnosis?,” “What is the predominant cell type?,” and “Where was this specimen taken from?” In addition to the knowledge-based questions, participants also were asked to rate their confidence in dermatopathology on a 5-point Likert scale ranging from 1 (not confident at all) to 5 (extremely confident). Participants completed the entire pretest before any information on the topic was provided. After the lecture, participants were asked to complete a posttest identical to the pretest and to rate their confidence in dermatopathology again on the same scale. The posttest included an additional question asking participants to rate the helpfulness of the lecture on a Likert scale ranging from 1 (not helpful at all) to 5 (extremely helpful). Participants completed the posttest within 48 hours of the lecture.

Overall, 15 learners participated in the pretest and 12 in the posttest. Of the 15 pretest participants, 3 were first-year residents and 12 were medical students. Similarly, in the posttest, 2 respondents were first-year residents and 10 were medical students. All responses contained complete pretests and posttests. The mean score on the pretest was 62%, whereas the mean score on the posttest was 75%. A paired t test indicated a statistically significant improvement (P=.017). In addition, the mean rating for confidence in dermatopathology knowledge before the lecture was 1.5 prior to the lecture and 2.6 after the lecture. A paired t test demonstrated statistical significance (P=.010). The mean rating of the helpfulness of the lecture was 4.67. The majority (91.7% [11/12]) of the participants gave a rating of 4 or 5.

Impact of the Lecture on Dermatopathology Knowledge

There is a gap in dermatopathology education early in medical training. Our introductory lecture led to higher post test scores and increased confidence in dermatopathology among medical students and dermatology residents, demonstrating the effectiveness of this kind of program in bridging this education gap. The majority of participants in our lecture said they found the session helpful. A previously published article called for early implementation of dermatology education as a whole in the medical curriculum due to lack of knowledge and confidence, and our introductory lecture may help to bridge this gap.⁸ Increasing dermatopathology content for medical students and first-year dermatology residents can expand knowledge, as shown by the increased scores on the posttest, and better supports learners transitioning to dermatology residency, where dermatopathology constitutes a large part of the overall curriculum.² More comprehensive knowledge of dermatopathology early in dermatology training also may help to better prepare residents to accurately diagnose and manage dermatologic conditions.

Pretest scores showed that the average confidence rating in dermatopathology among participants in our lecture was 1.5, which is rather low. This is consistent with prior studies that have found that residents feel that medical school inadequately prepared them for dermatology residency.^7,8 More than 87% (71/81) of medical students surveyed felt they received inadequate general dermatology training in medical school.⁹ This supports the proposed educational gap that is impacting confidence in overall dermatology knowledge, which includes dermatopathology. In our study, the average confidence rating increased by 1.1 points after the lecture, which was statistically significant (P=.010) and demonstrates that an introductory lecture serves as a feasible intervention to improve confidence in this area.

The feedback we received from participants in our lecture shows the benefits of an introductory interactive lecture with virtual dermatopathology images. Ngo et al2 highlighted how residents perceive virtual images to be superior to conventional microscopy for dermatopathology, which we utilized in our lecture. This method is not only cost effective but also provides a simple way for learners and facilitators to point out key findings on histopathology slides.²

Final Thoughts

Overall, implementing dermatopathology education early in training has a measurable impact on dermatopathology knowledge and confidence among medical students and first-year dermatology residents. An interactive lecture with virtual images similar to the one we describe here may better prepare learners for the transition to dermatology residency by addressing the educational gap in dermatopathology early in training.

The recent Supreme Court ruling that struck down affirmative action¹ has caused many initiatives aimed at promoting diversity, equity, and inclusion (DEI) to fall under scrutiny; however, the American Academy of Dermatology (AAD) published a statement of intent in 2022 recognizing and committing to DEI as a priority in the specialty.² In this study, we used a formal survey to investigate the perceptions of dermatology program directors (PDs) on DEI programming from the AAD and how DEI is integrated into the resident selection process at varying institutions.

Methods

We conducted a cross-sectional study of dermatology PDs across the United States from April 2024 to July 2024. Program directors were contacted via the Association of Professors of Dermatology PD listserve, which includes all 103 PDs who are members of the organization. Personalized survey links were created and sent individually to each PD’s email address. Thirty responses were received. All survey responses were captured anonymously. The survey consisted of 17 questions focusing on dermatology PD demographics and opinions on DEI initiatives in the AAD and in the dermatology resident selection process. Data were collected using Qualtrics survey tools and analyzed using Qualtrics reports.

Results

Demographics—A total of 30 completed surveys were received. Thirty-three percent (10/30) of respondents were from the Midwest, and 23% (7/30) were from the Northeast. The next most represented region was the West, with 20% (6/30) of respondents. The Southeast and Southwest were the least represented regions captured in our survey, accounting for 13% (4/30) and 10% (3/30) of respondents, respectively. After answering this initial demographic question, 1 respondent stopped the survey, bringing our new total to 29 respondents.

Most (66% [19/29]) of the survey respondents had served as PDs for 5 years or less. Sixty-nine percent (20/29) identified as female, while 31% (9/29) identified as male. Seventy-two percent (21/29) identified as White, 17% (5/29) identified as Asian, 3% (1/29) identified as Black/African American, 3% (1/29) identified as Hispanic or Latinx, and 3% (1/29) identified as mixed race.

Opinions on DEI Initiatives—When asked about their satisfaction level with the current amount of DEI efforts within the AAD, 17% (5/29) of respondents said they were very satisfied, 59% (17/29) said they were satisfied, 17% (5/29) said they were neutral, and 7% (2/29) said they were dissatisfied. Given that none of the questions were mandatory to answer before proceeding with the survey, there were variable response rates to each of the remaining questions, which may have caused respondents to answer only questions they felt strongly about.

Twenty respondents answered when prompted to further classify their level of satisfaction: 70% (14/20) said there should be more DEI efforts through the AAD providing financial support, and 50% (10/20) wanted more nonfinancial support. When given the opportunity to specify which DEI initiatives should be enhanced, the majority (67% [14/21]) of PDs chose the AAD’s health disparities curriculum, followed by the Diversity Mentorship Program (52% [11/21]), AAD Diversity Toolkit (43% [9/21]), and the Skin of Color Curriculum (43% [9/21]). Thiry-three percent (7/30) of PDs wanted enhancement of Medicine Without Barriers: Overcoming Unintended Bias in Practice (an AAD educational resource), and 19% (4/21) of respondents did not think any of the AAD’s DEI initiatives needed to be enhanced. There were 14 responses to a question about choosing which DEI initiatives to reduce with singular votes (7% [1/14] each) to reduce Medicine Without Barriers: Overcoming Unintended Bias in Practice and the Skin of Color Curriculum.

Our survey also invited PDs to introduce ideas for new DEI initiatives or programs. The following were suggestions offered by respondents: education for senior members of the AAD on the importance of DEI in dermatology, professional development resources directed toward academic faculty members to prepare them for interacting with and teaching residents from different backgrounds, and more advertisements and support for the AAD’s Diversity Champion Workshop.

DEI in Resident Selection—When asked about the role that DEI plays in how programs develop their match lists for residency, 13% (3/23) of PDs responded that it plays a very large role, 52% (12/23) stated that it plays a large role, 26% (6/23) responded that it plays somewhat of a role, 4% (1/23) stated that it plays a small role, and 4% (1/23) stated that it plays no role. Twenty-four percent (4/17) of respondents were PDs in states that have legislation limiting or defunding DEI initiatives at institutions of higher education. Another 12% (2/17) were from states where such legislation was pending a vote, while 59% (10/17) of respondents indicated that their state had not introduced such legislation. Four percent (1/17) indicated that they were from a state that had introduced legislation to limit or defund DEI initiatives that failed to pass. Only 17 respondents answered this question, which may be due to a lack of awareness among respondents of state-specific legislation on limiting or defunding DEI initiatives.

Resident Selection Factors—Ninety-six percent (22/23) of PDs stated that their residency program uses a holistic review that takes into account factors such as experiences (eg, volunteer work, research endeavors), personal attributes, and metrics in a balanced manner. No PDs offered United States Medical Licensing Examination Step score cutoffs or medical school clerkship cutoff grades. When asked to rank the importance placed on individual factors in the residency application, the following were ranked from most to least important in the process: performance on clerkships/rotations, performance on interviews, letters of recommendation, clerkship grades, United States Medical Licensing Examination Step scores, research content/ quality, race/ethnicity, history of teaching and mentorship, volunteering, and research amount. When asked to indicate the most pertinent factors used to incorporate DEI in resident selection, the most popular factor was lived experience/life, which was chosen by 90% (18/20) of PDs followed by 75% (15/20) of respondents incorporating underrepresented in medicine (URM) status (including Black, Latinx, and Native American applicants) and 70% (4/20) incorporating socioeconomic status. Sexual orientation and geographic ties of the applicant to the region of the residency program was incorporated by 45% (9/20) of respondents, and other characteristics of race and sex each were incorporated by 30% (6/20) of respondents. Religion was the least incorporated, with 10% (2/20) of PDs selecting this classification. In considering URM status when choosing dermatology residents, 100% (11/11) of respondents indicated that their institution promotes diversity as a part of the recruitment process. Eighty-two percent (9/11) of respondents try to recruit URM applicants to reflect their patient population, 82% (9/11) try as part of a belief that a diverse group benefits everyone in their program, and 45% (5/11) try in order to address societal inequities and as a broader mission to diversify the health care workforce. Seventy-three percent (8/11) indicated that they pay attention to URM status throughout the application process.

Comment

Diversity in the US population is steadily increasing. Within the past decade, the diversity index (the probability that 2 people chosen at random will be from different racial and ethnic groups) has grown from 54.9% in 2010 to 61.1% in 2020.³ There was a 24.9% increase in population groups other than non-Hispanic Whites from 2010 to 2020, an increase in diversity that was present in every region of the United States.⁴ The field of dermatology already does not reflect the racial distribution of the nation,⁴ with Black individuals accounting for 13.7% of the nation’s population but only 3% of dermatologists; similarly, Hispanic individuals account for 19.5% of the population but only comprise 4.2% of dermatologists.^5,6 There is overwhelming evidence that patients prefer to be diagnosed and treated by physicians who reflect their own demographics.⁷ Furthermore, physicians who prescribe treatment plans that reflect and respect socioeconomic and religious beliefs of the populations they serve enable patients to meet treatment expectations and experience better outcomes.⁸ Direct action is required to ensure that the specialty more accurately represents the evolving demographics of the country. This can be accomplished in myriad ways, including but not limited to cultural humility training⁹ for current dermatologists and trainees and recruitment of a more diverse workforce. These measures can ultimately improve treatment approaches and outcomes for dermatologic conditions across various groups.¹⁰

There are efforts by various dermatologic organizations, including the AAD, Society for Pediatric Dermatology, Pediatric Dermatology Research Alliance, Skin of Color Society, Women’s Dermatologic Society, and American Society for Dermatologic Surgery, that are focused on promoting DEI through research, education, and mentorship of potential future dermatologists.¹¹ However, the perceptions, opinions, and selection process instituted by PDs are most consequential in determining the diversity of the specialty, as PDs are at the forefront of establishing the next generation of dermatologists. Through this study, we have found that most PDs recognize the importance of diversity in residency education and recruitment without it being the only deciding factor.

The main limitation of this study was the small sample size, which may not adequately represent all dermatology residency programs accredited by the Accreditation Council for Graduate Medical Education as a result of selection bias toward respondents who were more likely to participate in survey-based research on topics of DEI.

Conclusion

This study revealed that, among dermatology residency PDs, there is interest in modifying the resources and initiatives surrounding DEI in the field. It also revealed that DEI remains a consideration in the resident selection process despite the recent Supreme Court ruling. In conclusion, there is an eagerness among dermatology PDs to incorporate DEI into resident selection even though gaps in knowledge and awareness remain.

The recent Supreme Court ruling that struck down affirmative action¹ has caused many initiatives aimed at promoting diversity, equity, and inclusion (DEI) to fall under scrutiny; however, the American Academy of Dermatology (AAD) published a statement of intent in 2022 recognizing and committing to DEI as a priority in the specialty.² In this study, we used a formal survey to investigate the perceptions of dermatology program directors (PDs) on DEI programming from the AAD and how DEI is integrated into the resident selection process at varying institutions.

Methods

We conducted a cross-sectional study of dermatology PDs across the United States from April 2024 to July 2024. Program directors were contacted via the Association of Professors of Dermatology PD listserve, which includes all 103 PDs who are members of the organization. Personalized survey links were created and sent individually to each PD’s email address. Thirty responses were received. All survey responses were captured anonymously. The survey consisted of 17 questions focusing on dermatology PD demographics and opinions on DEI initiatives in the AAD and in the dermatology resident selection process. Data were collected using Qualtrics survey tools and analyzed using Qualtrics reports.

Results

Demographics—A total of 30 completed surveys were received. Thirty-three percent (10/30) of respondents were from the Midwest, and 23% (7/30) were from the Northeast. The next most represented region was the West, with 20% (6/30) of respondents. The Southeast and Southwest were the least represented regions captured in our survey, accounting for 13% (4/30) and 10% (3/30) of respondents, respectively. After answering this initial demographic question, 1 respondent stopped the survey, bringing our new total to 29 respondents.

Most (66% [19/29]) of the survey respondents had served as PDs for 5 years or less. Sixty-nine percent (20/29) identified as female, while 31% (9/29) identified as male. Seventy-two percent (21/29) identified as White, 17% (5/29) identified as Asian, 3% (1/29) identified as Black/African American, 3% (1/29) identified as Hispanic or Latinx, and 3% (1/29) identified as mixed race.

Opinions on DEI Initiatives—When asked about their satisfaction level with the current amount of DEI efforts within the AAD, 17% (5/29) of respondents said they were very satisfied, 59% (17/29) said they were satisfied, 17% (5/29) said they were neutral, and 7% (2/29) said they were dissatisfied. Given that none of the questions were mandatory to answer before proceeding with the survey, there were variable response rates to each of the remaining questions, which may have caused respondents to answer only questions they felt strongly about.

Twenty respondents answered when prompted to further classify their level of satisfaction: 70% (14/20) said there should be more DEI efforts through the AAD providing financial support, and 50% (10/20) wanted more nonfinancial support. When given the opportunity to specify which DEI initiatives should be enhanced, the majority (67% [14/21]) of PDs chose the AAD’s health disparities curriculum, followed by the Diversity Mentorship Program (52% [11/21]), AAD Diversity Toolkit (43% [9/21]), and the Skin of Color Curriculum (43% [9/21]). Thiry-three percent (7/30) of PDs wanted enhancement of Medicine Without Barriers: Overcoming Unintended Bias in Practice (an AAD educational resource), and 19% (4/21) of respondents did not think any of the AAD’s DEI initiatives needed to be enhanced. There were 14 responses to a question about choosing which DEI initiatives to reduce with singular votes (7% [1/14] each) to reduce Medicine Without Barriers: Overcoming Unintended Bias in Practice and the Skin of Color Curriculum.

Our survey also invited PDs to introduce ideas for new DEI initiatives or programs. The following were suggestions offered by respondents: education for senior members of the AAD on the importance of DEI in dermatology, professional development resources directed toward academic faculty members to prepare them for interacting with and teaching residents from different backgrounds, and more advertisements and support for the AAD’s Diversity Champion Workshop.

DEI in Resident Selection—When asked about the role that DEI plays in how programs develop their match lists for residency, 13% (3/23) of PDs responded that it plays a very large role, 52% (12/23) stated that it plays a large role, 26% (6/23) responded that it plays somewhat of a role, 4% (1/23) stated that it plays a small role, and 4% (1/23) stated that it plays no role. Twenty-four percent (4/17) of respondents were PDs in states that have legislation limiting or defunding DEI initiatives at institutions of higher education. Another 12% (2/17) were from states where such legislation was pending a vote, while 59% (10/17) of respondents indicated that their state had not introduced such legislation. Four percent (1/17) indicated that they were from a state that had introduced legislation to limit or defund DEI initiatives that failed to pass. Only 17 respondents answered this question, which may be due to a lack of awareness among respondents of state-specific legislation on limiting or defunding DEI initiatives.

Resident Selection Factors—Ninety-six percent (22/23) of PDs stated that their residency program uses a holistic review that takes into account factors such as experiences (eg, volunteer work, research endeavors), personal attributes, and metrics in a balanced manner. No PDs offered United States Medical Licensing Examination Step score cutoffs or medical school clerkship cutoff grades. When asked to rank the importance placed on individual factors in the residency application, the following were ranked from most to least important in the process: performance on clerkships/rotations, performance on interviews, letters of recommendation, clerkship grades, United States Medical Licensing Examination Step scores, research content/ quality, race/ethnicity, history of teaching and mentorship, volunteering, and research amount. When asked to indicate the most pertinent factors used to incorporate DEI in resident selection, the most popular factor was lived experience/life, which was chosen by 90% (18/20) of PDs followed by 75% (15/20) of respondents incorporating underrepresented in medicine (URM) status (including Black, Latinx, and Native American applicants) and 70% (4/20) incorporating socioeconomic status. Sexual orientation and geographic ties of the applicant to the region of the residency program was incorporated by 45% (9/20) of respondents, and other characteristics of race and sex each were incorporated by 30% (6/20) of respondents. Religion was the least incorporated, with 10% (2/20) of PDs selecting this classification. In considering URM status when choosing dermatology residents, 100% (11/11) of respondents indicated that their institution promotes diversity as a part of the recruitment process. Eighty-two percent (9/11) of respondents try to recruit URM applicants to reflect their patient population, 82% (9/11) try as part of a belief that a diverse group benefits everyone in their program, and 45% (5/11) try in order to address societal inequities and as a broader mission to diversify the health care workforce. Seventy-three percent (8/11) indicated that they pay attention to URM status throughout the application process.

Comment

Diversity in the US population is steadily increasing. Within the past decade, the diversity index (the probability that 2 people chosen at random will be from different racial and ethnic groups) has grown from 54.9% in 2010 to 61.1% in 2020.³ There was a 24.9% increase in population groups other than non-Hispanic Whites from 2010 to 2020, an increase in diversity that was present in every region of the United States.⁴ The field of dermatology already does not reflect the racial distribution of the nation,⁴ with Black individuals accounting for 13.7% of the nation’s population but only 3% of dermatologists; similarly, Hispanic individuals account for 19.5% of the population but only comprise 4.2% of dermatologists.^5,6 There is overwhelming evidence that patients prefer to be diagnosed and treated by physicians who reflect their own demographics.⁷ Furthermore, physicians who prescribe treatment plans that reflect and respect socioeconomic and religious beliefs of the populations they serve enable patients to meet treatment expectations and experience better outcomes.⁸ Direct action is required to ensure that the specialty more accurately represents the evolving demographics of the country. This can be accomplished in myriad ways, including but not limited to cultural humility training⁹ for current dermatologists and trainees and recruitment of a more diverse workforce. These measures can ultimately improve treatment approaches and outcomes for dermatologic conditions across various groups.¹⁰

There are efforts by various dermatologic organizations, including the AAD, Society for Pediatric Dermatology, Pediatric Dermatology Research Alliance, Skin of Color Society, Women’s Dermatologic Society, and American Society for Dermatologic Surgery, that are focused on promoting DEI through research, education, and mentorship of potential future dermatologists.¹¹ However, the perceptions, opinions, and selection process instituted by PDs are most consequential in determining the diversity of the specialty, as PDs are at the forefront of establishing the next generation of dermatologists. Through this study, we have found that most PDs recognize the importance of diversity in residency education and recruitment without it being the only deciding factor.

The main limitation of this study was the small sample size, which may not adequately represent all dermatology residency programs accredited by the Accreditation Council for Graduate Medical Education as a result of selection bias toward respondents who were more likely to participate in survey-based research on topics of DEI.

Conclusion

This study revealed that, among dermatology residency PDs, there is interest in modifying the resources and initiatives surrounding DEI in the field. It also revealed that DEI remains a consideration in the resident selection process despite the recent Supreme Court ruling. In conclusion, there is an eagerness among dermatology PDs to incorporate DEI into resident selection even though gaps in knowledge and awareness remain.

The recent Supreme Court ruling that struck down affirmative action¹ has caused many initiatives aimed at promoting diversity, equity, and inclusion (DEI) to fall under scrutiny; however, the American Academy of Dermatology (AAD) published a statement of intent in 2022 recognizing and committing to DEI as a priority in the specialty.² In this study, we used a formal survey to investigate the perceptions of dermatology program directors (PDs) on DEI programming from the AAD and how DEI is integrated into the resident selection process at varying institutions.

Methods

We conducted a cross-sectional study of dermatology PDs across the United States from April 2024 to July 2024. Program directors were contacted via the Association of Professors of Dermatology PD listserve, which includes all 103 PDs who are members of the organization. Personalized survey links were created and sent individually to each PD’s email address. Thirty responses were received. All survey responses were captured anonymously. The survey consisted of 17 questions focusing on dermatology PD demographics and opinions on DEI initiatives in the AAD and in the dermatology resident selection process. Data were collected using Qualtrics survey tools and analyzed using Qualtrics reports.

Results

Demographics—A total of 30 completed surveys were received. Thirty-three percent (10/30) of respondents were from the Midwest, and 23% (7/30) were from the Northeast. The next most represented region was the West, with 20% (6/30) of respondents. The Southeast and Southwest were the least represented regions captured in our survey, accounting for 13% (4/30) and 10% (3/30) of respondents, respectively. After answering this initial demographic question, 1 respondent stopped the survey, bringing our new total to 29 respondents.

Most (66% [19/29]) of the survey respondents had served as PDs for 5 years or less. Sixty-nine percent (20/29) identified as female, while 31% (9/29) identified as male. Seventy-two percent (21/29) identified as White, 17% (5/29) identified as Asian, 3% (1/29) identified as Black/African American, 3% (1/29) identified as Hispanic or Latinx, and 3% (1/29) identified as mixed race.

Opinions on DEI Initiatives—When asked about their satisfaction level with the current amount of DEI efforts within the AAD, 17% (5/29) of respondents said they were very satisfied, 59% (17/29) said they were satisfied, 17% (5/29) said they were neutral, and 7% (2/29) said they were dissatisfied. Given that none of the questions were mandatory to answer before proceeding with the survey, there were variable response rates to each of the remaining questions, which may have caused respondents to answer only questions they felt strongly about.

Twenty respondents answered when prompted to further classify their level of satisfaction: 70% (14/20) said there should be more DEI efforts through the AAD providing financial support, and 50% (10/20) wanted more nonfinancial support. When given the opportunity to specify which DEI initiatives should be enhanced, the majority (67% [14/21]) of PDs chose the AAD’s health disparities curriculum, followed by the Diversity Mentorship Program (52% [11/21]), AAD Diversity Toolkit (43% [9/21]), and the Skin of Color Curriculum (43% [9/21]). Thiry-three percent (7/30) of PDs wanted enhancement of Medicine Without Barriers: Overcoming Unintended Bias in Practice (an AAD educational resource), and 19% (4/21) of respondents did not think any of the AAD’s DEI initiatives needed to be enhanced. There were 14 responses to a question about choosing which DEI initiatives to reduce with singular votes (7% [1/14] each) to reduce Medicine Without Barriers: Overcoming Unintended Bias in Practice and the Skin of Color Curriculum.

Our survey also invited PDs to introduce ideas for new DEI initiatives or programs. The following were suggestions offered by respondents: education for senior members of the AAD on the importance of DEI in dermatology, professional development resources directed toward academic faculty members to prepare them for interacting with and teaching residents from different backgrounds, and more advertisements and support for the AAD’s Diversity Champion Workshop.

DEI in Resident Selection—When asked about the role that DEI plays in how programs develop their match lists for residency, 13% (3/23) of PDs responded that it plays a very large role, 52% (12/23) stated that it plays a large role, 26% (6/23) responded that it plays somewhat of a role, 4% (1/23) stated that it plays a small role, and 4% (1/23) stated that it plays no role. Twenty-four percent (4/17) of respondents were PDs in states that have legislation limiting or defunding DEI initiatives at institutions of higher education. Another 12% (2/17) were from states where such legislation was pending a vote, while 59% (10/17) of respondents indicated that their state had not introduced such legislation. Four percent (1/17) indicated that they were from a state that had introduced legislation to limit or defund DEI initiatives that failed to pass. Only 17 respondents answered this question, which may be due to a lack of awareness among respondents of state-specific legislation on limiting or defunding DEI initiatives.

Resident Selection Factors—Ninety-six percent (22/23) of PDs stated that their residency program uses a holistic review that takes into account factors such as experiences (eg, volunteer work, research endeavors), personal attributes, and metrics in a balanced manner. No PDs offered United States Medical Licensing Examination Step score cutoffs or medical school clerkship cutoff grades. When asked to rank the importance placed on individual factors in the residency application, the following were ranked from most to least important in the process: performance on clerkships/rotations, performance on interviews, letters of recommendation, clerkship grades, United States Medical Licensing Examination Step scores, research content/ quality, race/ethnicity, history of teaching and mentorship, volunteering, and research amount. When asked to indicate the most pertinent factors used to incorporate DEI in resident selection, the most popular factor was lived experience/life, which was chosen by 90% (18/20) of PDs followed by 75% (15/20) of respondents incorporating underrepresented in medicine (URM) status (including Black, Latinx, and Native American applicants) and 70% (4/20) incorporating socioeconomic status. Sexual orientation and geographic ties of the applicant to the region of the residency program was incorporated by 45% (9/20) of respondents, and other characteristics of race and sex each were incorporated by 30% (6/20) of respondents. Religion was the least incorporated, with 10% (2/20) of PDs selecting this classification. In considering URM status when choosing dermatology residents, 100% (11/11) of respondents indicated that their institution promotes diversity as a part of the recruitment process. Eighty-two percent (9/11) of respondents try to recruit URM applicants to reflect their patient population, 82% (9/11) try as part of a belief that a diverse group benefits everyone in their program, and 45% (5/11) try in order to address societal inequities and as a broader mission to diversify the health care workforce. Seventy-three percent (8/11) indicated that they pay attention to URM status throughout the application process.

Comment

Diversity in the US population is steadily increasing. Within the past decade, the diversity index (the probability that 2 people chosen at random will be from different racial and ethnic groups) has grown from 54.9% in 2010 to 61.1% in 2020.³ There was a 24.9% increase in population groups other than non-Hispanic Whites from 2010 to 2020, an increase in diversity that was present in every region of the United States.⁴ The field of dermatology already does not reflect the racial distribution of the nation,⁴ with Black individuals accounting for 13.7% of the nation’s population but only 3% of dermatologists; similarly, Hispanic individuals account for 19.5% of the population but only comprise 4.2% of dermatologists.^5,6 There is overwhelming evidence that patients prefer to be diagnosed and treated by physicians who reflect their own demographics.⁷ Furthermore, physicians who prescribe treatment plans that reflect and respect socioeconomic and religious beliefs of the populations they serve enable patients to meet treatment expectations and experience better outcomes.⁸ Direct action is required to ensure that the specialty more accurately represents the evolving demographics of the country. This can be accomplished in myriad ways, including but not limited to cultural humility training⁹ for current dermatologists and trainees and recruitment of a more diverse workforce. These measures can ultimately improve treatment approaches and outcomes for dermatologic conditions across various groups.¹⁰

There are efforts by various dermatologic organizations, including the AAD, Society for Pediatric Dermatology, Pediatric Dermatology Research Alliance, Skin of Color Society, Women’s Dermatologic Society, and American Society for Dermatologic Surgery, that are focused on promoting DEI through research, education, and mentorship of potential future dermatologists.¹¹ However, the perceptions, opinions, and selection process instituted by PDs are most consequential in determining the diversity of the specialty, as PDs are at the forefront of establishing the next generation of dermatologists. Through this study, we have found that most PDs recognize the importance of diversity in residency education and recruitment without it being the only deciding factor.

The main limitation of this study was the small sample size, which may not adequately represent all dermatology residency programs accredited by the Accreditation Council for Graduate Medical Education as a result of selection bias toward respondents who were more likely to participate in survey-based research on topics of DEI.

Conclusion

This study revealed that, among dermatology residency PDs, there is interest in modifying the resources and initiatives surrounding DEI in the field. It also revealed that DEI remains a consideration in the resident selection process despite the recent Supreme Court ruling. In conclusion, there is an eagerness among dermatology PDs to incorporate DEI into resident selection even though gaps in knowledge and awareness remain.