Using Lessons From an Underserved Family Medicine Dermatology

Using Lessons From an Underserved Family Medicine Dermatology Fellowship To Improve Family Medicine Resident Learning in Dermatology Richard P. Usatine, MD, FAAFP Professor, Family and Community Medicine Professor, Dermatology and Cutaneous Surgery Fellowship Director, Underserved Family Medicine Dermatology Fellowship Medical Director, University Skin Clinic University of Texas HSC, San Antonio Jonathan Karnes, MD Maine Dartmouth Family Medicine Residency MDFMR Dermatology Services Assistant Professor of Family and Community Medicine Geisel School of Medicine at Dartmouth

Objectives • Describe the underserved family medicine dermatology fellowship. • Discuss the need for increased access to dermatologic services and describe how a more highly trained family medicine workforce can help alleviate the current dermatology shortages. • List ideas and resources for improving the dermatology curriculum within family medicine residencies.

Background • National shortage of dermatologists • Severe shortage of dermatologists taking care of underserved patients without insurance or with Medicaid. • Current wait times for appointments with dermatologists often ranges from 3 to 6 months nationwide.

Fellowship • Began in 2009 and takes two fellows yearly • One year program • Medical and surgical dermatology (excluding cosmetics) • Skin Clinic (under FM, started in 2006) • Training with Dermatology residents and faculty

FM Skills • Precept medical students and direct the primary care in several medical student-run free clinics. • Serve homeless families, recent immigrants and refugees, and women in substance abuse recovery. • Develop teaching abilities and maintain family medicine skills.

Impact on FM residents • FM residents all do one month in Skin Clinic in their 2 nd year • Many choose to do electives in their 3 rd year • Lectures and workshops taught by fellowship faculty

Goal • One goal of the fellowship is to improve the quality of dermatology training across the board for family physicians. • The faculty and fellows in the program have been instrumental in developing new resources and curricula in dermatology geared for family medicine residents.

Resources from fellowship • Dermatologic and Cosmetic Procedures in Office Practice. Book, app, DVD. 2012. • The Color Atlas of Family Medicine, 2 nd Edition. Mc. Graw-Hill. 2013. Book, app. • Cutaneous Cryosurgery. CRC Press. 2014 • AAFP Skin Course. Live course and enduring material. • Many articles in AFP and JFP • Dermoscopy App free

Fellowship Evaluation (3/31/15) • Completed by: – 5/6 graduated fellows – 2/2 current fellows

Current practice of 6 graduates (in order) 1. 100% dermatology in private practice 2. 100% dermatology as a separate department in a family medicine residency 3. 40% Dermatology 40% Family Medicine (80% outpatient , 20% inpatient) 20% Academic 4. 30% dermatology in primary care group practice 5. 20% dermatology in Urgent Care/Occupational Medicine 6. 100% dermatology in Skin Clinic

Strengths • Plenty of exposure to full spectrum dermatology both clinical and procedural. Didactic sessions with dermatology residency program. • The mission of this Fellowship in caring for the needs of the underserved is unique in dermatology training programs. • The variety and complexity of medical and surgical patients is ideal preparation for full spectrum dermatology practice. • The partnership with a dermatology residency program coupled with the fellowship gives both the rigor and the experience to practice safely and effectively. • For those interested in academic medicine, the fellowship offers a chance to write and edit medical literature with a seasoned author and teacher.

Strengths (2) • Clinical practice at the skin clinic provides the opportunity to learn theory and apply what you are learning into practice. Also good to learn from dermatologists - lectures and histopathology by derm were also helpful. • Evaluating and treating patients in the skin clinic, having our own patients for continuity. Good blend of mentorship from a Family Medicine physician, mixed with didactic learning with the dermatology residents. • Great hands-on patient care. The population of patients (underserved) truly need and appreciate the care.

All felt competent in the diagnosis and management of these 30: • • • • Acne Atopic dermatitis/Eczema Psoriasis Skin cancers childhood hemangiomas rosacea pseudofolliculitis hidradenitis bacterial skin infections viral skin infections fungal skin infections infestations contact dermatitis psychogenic dermatoses • • • • seborrheic dermatitis lichen planus benign neoplasms nevi actinic keratoses Bowen's disease granuloma annulare erythema multiforme erythema nodosum alopecia nail diseases pigmentary problems vascular skin lesions cutaneous drug reactions keloids urticaria and angioedema

Less than all (for these 6) 6/7 for 5/7 for • erythroderma • sarcoidosis • pyoderma • autoimmune gangrenosum bullous diseases • vasculitis • connective tissue diseases of the skin • photosensitivity

3 rd Year residents (only 11 diagnoses showing competence greater than 50%) actinic keratoses 60. 00% urticaria and angioedema 60. 00% keloids 60. 00% Psoriasis 60. 00% seborrheic dermatitis 60. 00% bacterial skin infections 60. 00% fungal skin infections 70. 00% contact dermatitis 70. 00% alopecia 70. 00% Acne 90. 00% Atopic dermatitis/Eczema 90. 00%

I feel competent in the following dermatologic procedures: 1. shave biopsy 2. punch biopsy 3. elliptical excision 4. cryosurgery 5. electrosurgery 6. electrodesiccation and curettage 7. excision of cysts 8. excision of lipomas 9. intralesional injections 10. Incision and drainage 11. wound care

Nail matrix biopsy • 6/7 reported competence

3 rd year residents (only 5 procedures showing competence greater than 50%) • Incision and drainage 100. 00% • • shave biopsy 66. 67% • • wound care 66. 67% • • intralesional injections 66. 67% • • punch biopsy 55. 56% excision of lipomas 44. 44% excision of cysts 44. 44% cryosurgery 33. 33% electrodesiccation and curettage 11. 11% electrosurgery 0. 00% elliptical excision 0. 00% nail matrix biopsy 0. 00%

I feel competent in the use of the following systemic medications: 7/7 for • Isotretinoin • Methotrexate • Biologics • Prednisone

I feel competent in the use of the following systemic medications: • 6/7 Acitretin • 5/7 Cyclosporin • 4/7 Mycophenolate mofetil • 3/7 Azathioprine • Residents: • Only reported competence with prednisone.

100% • Use dermoscopy • Feel competent to read pathology reports and be able to correlate histological descriptions with clinical diagnoses • Feel prepared to practice a full spectrum of medical and surgical dermatology • 0% or 3 rd year residents

Dermascopes

Dermoscopy Resources • • Free dermoscopy app - Dermoscopy: Two Step Algorithm. Available on i. Tunes and www. usatinemedia. com. Authors: Marghoob AA, Usatine RP, Jaimes N. Released in 2014. Dermoscopy. Website from Italy that includes a free dermoscopy tutorial— http: //www. dermoscopy. org/ International Dermoscopy Society, http: //www. dermoscopy-ids. org/ Johr R, Stolz W. Dermoscopy: An Illustrated Self-Assessment Guide. New York, NY: Mc. Graw-Hill; 2010, with an interactive app: see www. usatinemedia. com Marghoob A, Usatine R. Dermoscopy. In: Usatine R, Pfenninger J, Stulberg D, Small R, eds. Dermatologic and Cosmetic Procedures in Office Practice. Philadelphia, PA: Elsevier; 2012. Marghoob AA, Usatine RP, Jaimes N. Dermoscopy. In: Usatine R, Smith M, Mayeaux EJ, Chumley H. Color Atlas of Family Medicine, 2 nd Edition. New York, NY: Mc. Graw-Hill; 2013 Marghoob AA, Usatine RP, Jaimes N. Dermoscopy for the family physician. Am Fam Physician. 2013 Oct 1; 88(7): 441 -50.

100% free on i. Tunes and Google play

Dermoscopy Courses • American Dermoscopy Meeting is held yearly in the summer in a national park: • http: //www. americandermoscopy. com/ • Memorial Sloan-Kettering Cancer Center holds a yearly dermoscopy workshop each fall in New York City: http: //www. mskcc. org/events/ • American Academy of Family Physicians (AAFP) yearly fall scientific assembly offers dermoscopy workshops: http: //www. aafp. org/events/assembly. html • AAFP sponsors a course on “Skin Problems and Diseases” that includes a dermoscopy workshop: http: //www. aafp. org/cme/

Final comment • The fellowship was great! Between the hands on patient care opportunities, didactics and dermpath exposure, I couldn't have asked for a more comprehensive fellowship training experience. I feel confident that I could manage >90% of dermatologic problems that walked into my office following fellowship training.