CLINICAL AND LABORATORY INVESTIGATIONS Pediatric Dermatology Vol. 31 No. 2 131–137, 2014
Pediatric Dermatology Training Survey of United States Dermatology Residency Programs Rajiv I. Nijhawan, M.D., Joni M. Mazza, M.D., and Nanette B. Silverberg, M.D. Department of Dermatology, St. Luke’s-Roosevelt and Beth Israel Medical Centers, New York City, New York
Abstract: Variability exists in pediatric dermatology education for dermatology residents. We sought to formally assess the pediatric dermatology curriculum and experience in a dermatology residency program. Three unique surveys were developed for dermatology residents, residency program directors, and pediatric dermatology fellowship program directors. The surveys consisted of questions pertaining to residency program characteristics. Sixty-three graduating third-year residents, 51 residency program directors, and 18 pediatric dermatology fellowship program directors responded. Residents in programs with one or more full-time pediatric dermatologist were more likely to feel very competent treating children and were more likely to be somewhat or extremely satisfied with their pediatric curriculums than residents in programs with no full-time pediatric dermatologist (50.0% vs 5.9%, p = 0.002, and 85.3% vs 52.9%, p < 0.001, respectively). Residents in programs with no full-time pediatric dermatologist were the only residents who were somewhat or extremely dissatisfied with their pediatric training. Residency program directors were more satisfied with their curriculums when there was one or more pediatric dermatologist on staff (p < 0.01). Residents in programs with pediatric dermatology fellowships were much more likely to report being extremely satisfied than residents in programs without a pediatric dermatology fellowship (83.3% vs 21.2%; p < 0.001). The results of this survey support the need for dermatology residency programs to continue to strengthen their pediatric dermatology curriculums, especially through the recruitment of full-time pediatric dermatologists.
Pediatric dermatology is an important component of the core curriculum of dermatology residency training. It is estimated that 30% of dermatology office visits are for children, so it is essential that dermatologists have a certain degree of competence and confidence in pediatric dermatology (1,2).
Considerable variability exists in the type and extent of pediatric dermatology education that residents receive nationally. Factors such as geographic location, patient population, number of pediatric didactic sessions, and presence of a full-time pediatric dermatologist are all variables during training.
Address correspondence to Joni M. Mazza, M.D., Department of Dermatology, St. Luke’s-Roosevelt and Beth Israel Medical Centers, 1090 Amsterdam Avenue, Suite 11B, New York, NY 10023, or e-mail: [email protected]. DOI: 10.1111/pde.12266
© 2013 Wiley Periodicals, Inc.
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Previous studies have reported a national shortage of pediatric dermatologists at academic training centers and in clinical practice (1,2). Whereas other dermatologic subspecialities such as procedural dermatology, dermatopathology, contact dermatitis, and skin-of-color education have been formally assessed in the context of residency training (3–7), to our knowledge no previous study has formally assessed pediatric dermatology curriculums and experiences in dermatology residency programs.
METHODS Study Population and Survey Methodology
expectations and satisfaction with pediatric dermatology training in dermatology residency programs. All responses were collected anonymously. Statistical Analysis Descriptive frequencies, medians, and means were calculated to describe survey responses. Chi-square statistics were calculated to assess the independence of study variables. RESULTS Sixty-three graduating third-year residents out of 399 nationwide (response rate 15.8%), 51 residency program directors (response rate 45.5%), and 18 pediatric dermatology fellowship program directors (response rate 62.1%) responded. The mean age of graduating resident respondents was 32.4 years (range 28–44 years). The residency program characteristics of the respondents, including children’s hospital and pediatric dermatology fellowship affiliations, are detailed in Table 1.
One hundred fourteen Accreditation Council for Graduate Medical Education (ACGME)-approved dermatology residency programs and their respective program directors were identified using the ACGME website (https://www.acgme.org/ads/Public/Reports/ Report/1, accessed May 10, 2012). Two programs that did not have any third-year residents were excluded from the study. Twenty-nine pediatric dermatology fellowship directors recognized by the American Board of Dermatology (ABD) were identified in July 2012 using the ABD website (http://www.abderm.org/subspecialties/ped_derm_programs.pdf, accessed June 7, 2012). The authors developed three separate, unique surveys addressing pediatric dermatology education that were posted using an independent online host (http://www.surveymonkey.com) for the study groups: third-year residents graduating in June 2012 (GRs), dermatology residency program directors (RPDs) (n = 112), and pediatric dermatology fellowship program directors (FPDs) (n = 29). A link to the relevant survey was e-mailed to the respective targeted study groups. E-mail addresses were compiled for 127 GRs from 38 programs and the remaining 74 program coordinators requested that the link to the survey be forwarded to the GRs by the program coordinator directly. The study groups were e-mailed monthly from June to August 2012.
Table 2 details clinical training specific to pediatric dermatology. Residents receive the vast majority of their pediatric dermatology clinical training in resident clinics, accounting for 70.1% of their pediatric dermatology exposure. According to the RPDs, 56.5% of dermatology residency programs have pediatric-specific clinics, the percentage being much greater at programs with fellowships (76.9%, p = 0.08). When they are in a resident clinic, 62.3% of GRs reported that they are the primary provider for patients. Approximately half of residency programs nationally have pediatric dermatology–specific rotations, although according to RPDs, residencies with a fellowship program at their respective institutions are more likely to have dedicated rotations (69.2% vs 42.4%, p = 0.10). The range reported of required time spent on this rotation throughout 3 years of residency varied from 8 to 16 weeks.
Survey Content
Didactic Education
The surveys (Tables S1–S3) consisted of questions pertaining to residency program characteristics, type and extent of clinical exposure to pediatric dermatology, amount of didactic time dedicated specifically to this subspecialty, residents’ perceived comfort level and confidence in independently managing conditions more prevalent in pediatric populations, and overall
Table 2 details didactic sessions. All three groups of respondents reported a range of 10.8% to 13.8% with regard to the percentage of pediatric dermatology didactic time. Although RPDs and FPDs felt that GRs had 4.6 and 4.9 hours, respectively, of pediatric dermatology didactic time per month, GRs reported receiving 2.3 hours per month. According
Clinical Training
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TABLE 1. Residency Program Characteristics Dermatology residents n
%
Residency directors n
Fellowship directors %
Sex Male 27 42.9 N/A N/A Female 36 57.1 Region of United States Northeast 25 39.7 15 29.4 Southeast 6 9.5 7 13.7 Midwest 20 31.7 14 27.5 South 4 6.3 7 13.7 Southwest 1 1.6 2 3.9 West 7 11.1 6 11.8 ≤5 miles from a major urban city Yes 54 85.7 34 66.7 No 9 14.3 17 33.3 Medical school affiliation Yes 61 96.8 50 98.0 No 2 3.2 1 2.0 Children’s hospital affiliation Yes 42 66.7 45 88.2 No 21 33.3 6 11.8 Pediatrics residency program Yes 56 88.9 48 94.1 No 7 11.1 3 5.9 Number of full-time pediatric dermatologists on staff 0 21 33.3 22 43.1 1 16 25.4 12 23.5 2 12 19.0 9 17.6 3 4 6.3 4 7.8 4 1 1.6 1 2.0 >4 9 14.3 3 5.9 Number of part-time pediatric dermatologists on staff (if answered “0” to previous question) 0 15 71.4 13 59.1 1 6 28.6 9 40.9 Pediatric dermatology fellowship Yes 19 35.8 15 29.4 No 34 64.2 36 70.6 Plan for program to apply for a fellowship in next 2 years Yes N/A N/A 3 8.3 No 33 91.7 Will you be completing a pediatric dermatology fellowship next year? Yes 3 5.9 N/A N/A No 48 94.1
to GRs, programs with a pediatric dermatology fellowship were more likely to have pediatric specific rotations (73.7% vs 41.2%, p = 0.02), didactic lectures (89.5% vs 61.8%, p = 0.03), and pediatric journal review (73.7% vs 14.7%, p < 0.001). The most commonly reviewed pediatric-specific textbooks according to GRs, RPDs, and FPDs are listed in Table 2. Of note, 39.6% of GRs reported not reviewing any pediatric dermatology-specific text, compared with 15.2% of RPDs and 23.5% of FPDs. Resident Comfort Levels GRs were asked to rate their comfort level in independently managing various pediatric dermato-
n
%
N/A
N/A
5 2 6 1 1 3
27.8 11.1 33.3 5.6 5.6 16.7
15 3
83.3 16.7
17 1
94.4 5.6
18 0
100 0
17 1
94.4 5.6
0 2 7 3 1 5
0 11.1 38.9 16.7 5.6 27.8
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
logic conditions and the use of systemic medications, phototherapy and lasers in children (Table 3). More than 90% of GRs felt very comfortable treating patients with atopic dermatitis (94.1%), scalp psoriasis (92.2%), and tinea capitis (90.2%), but comfort levels decreased for more challenging conditions, such as mycosis fungoides (13.7%) and disorders with a high risk of malignancy (5.9%). Residents’ Perception of Competency GRs were asked questions on their self-perception of their competence in independently managing pediatric patients (Table 4). The majority of third-year residents (56.9%) felt only somewhat competent in independently managing pediatric patients once they
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TABLE 2. Resident Clinical and Didactic Exposure Dermatology residents, % (n) Pediatric dermatology clinical exposure setting Resident clinic 70.1 Private practice 17.6 Inpatient consult service 16.2 Fellow clinic 1.0 External rotations 5.8 Clinics exclusive for pediatric patients or mixed with adults Exclusive (only pediatric) 69.8 (37) Mixed (pediatric and adult) 30.2 (16) Residents’ role in managing pediatric dermatology patients (check all applicable) Primary provider in resident/fellow clinic 62.3 Primary provider in private clinic 39.6 Assist attending in private clinic 24.5 Frequency that resident is assigned to work in pediatric dermatology clinic No separate clinic for pediatric patients 17.6 (9) ~1 half-day clinic per month 21.6 (11) ~2 half-day clinics per month 11.8 (6) ~3 half-day clinics per month 17.6 (9) ~1 half-day clinic per week 15.7 (8) ~2 half-day clinics per week 15.7 (8) Pediatric dermatology–specific rotation Yes 52.8 (28) No 47.2 (25) Amount of resident education dedicated to pediatric dermatology % 10.8 Hours per month 2.3 Pediatric dermatology journal club Yes 35.8 (18) No 64.2 (34) Pediatric dermatology–specific lectures and kodachromes Yes 71.7 (38) No 28.3 (15) Textbooks None 39.6 (21) Color Atlas and Synopsis of Pediatric Dermatology (eds. Kane, Lio, 1.9 (1) Stratigos, and Johnson) Color Textbook of Pediatric Dermatology (eds. Weston, Lane, and 0 (0) Morelli) Harper’s Textbook of Pediatric Dermatology (eds. Irvine, Hoeger, 0 (0) and Yan) Hurwitz Clinical Pediatric Dermatology (eds. Paller and Mancini) 22.6 (12) Pediatric Dermatology (eds. Schachner and Hansen) 5.7 (3) Pediatric Dermatology: Requisites in Dermatology (eds. Pride, Yan 1.9 (1) and Zaenglein) Genodermatoses: A Clinical Guide to Genetic Disorders (ed. Spitz) 50.9 (27) Textbook of Pediatric Dermatology (eds. Harper, Oranje, and Prose) 1.9 (1) Other 1.9 (1)
graduate from residency. Residents who received pediatric-specific lectures or kodachromes (reviews of visual images of skin conditions) were more likely to feel very competent than those who did not receive these sessions (88.9 vs 11.1%, p = 0.08). GRs with separate pediatric clinics even just 0.5 days per month were much more likely to feel very competent in treating children (p = 0.03) than those who saw children in a mixed adult and pediatric clinic. GRs with a pediatric dermatology fellowship at their programs were more likely to feel very competent (55.6%) than residents in a program without a
Residency directors, % (n)
Fellowship directors, % (n)
71.5 19.4 11.6 3.3 6.6
66.7 28.2 13.5 5.0 0.7
56.5 (26) 43.5 (20)
94.1 (16) 5.9 (1)
54.3 47.3 28.3
47.1 35.3 58.8
22.2 (10) 15.6 (7) 17.8 (8) 4.4 (2) 31.1 (14) 8.9 (4)
0 (0) 11.8 (2) 11.8 (2) 17.6 (3) 47.1 (8) 11.8 (2)
50 (23) 50 (23)
82.4 (14) 17.6 (3)
11.4 4.6
13.8 4.9
52.2 (24) 47.8 (22)
76.5 (13) 23.5 (4)
91.3 (42) 8.7 (4)
100 (17) 0 (0)
15.2 (7) 6.5 (3)
23.5 (4) 0 (0)
17.4 (8)
17.6 (3)
4.3 (2)
5.9 (1)
60.9 (28) 17.4 (8) 2.2 (1)
70.6 (12) 17.6 (3) 0 (0)
69.6 (32) 15.2 (7) 6.5 (3)
35.3 (6) 17.6 (3) 11.8 (2)
fellowship (24.2%, p = 0.05). In addition, those who felt extremely satisfied with their pediatric dermatology program were much more likely to feel very competent in independently treating patients after residency (p < 0.001). Pediatric Dermatology Curriculum Expectations and Satisfaction GRs, RPDs, and FPDs were asked questions on pediatric dermatology curriculum expectations and satisfaction (Table 4). Although the majority of
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TABLE 3. Resident Comfort Level in Management and Procedures Very comfortable, % (n)
Somewhat comfortable, % (n)
Not very comfortable, % (n)
Not comfortable at all, % (n)
Would not use this treatment for disease or perform on a pediatric patient, % (n)
On the following scale, please rate your comfort level in INDEPENDENTLY starting a pediatric patient at any age (including newborns, infants, and children) on one of the following systemic medications Oral propranolol in the inpatient or 29.4 (15) 39.2 (20) 21.6 (11) 9.8 (5) 0.0 (0) outpatient setting for an infantile hemangioma Oral prednisone in the outpatient setting 54.9 (28) 37.3 (19) 7.8 (4) 0.0 (0) 0.0 (0) for poison ivy in a child Oral methotrexate in the outpatient 23.5 (12) 49.0 (25) 23.5 (12) 2.9 (2) 0.0 (0) setting for morphea/scleroderma Subcutaneous biologic therapy (e.g., 27.5 (14) 47.1 (24) 17.6 (9) 7.8 (9) 0.0 (0) etanercept, adalimumab) for pediatric or adolescent psoriasis Pulsed oral prednisone for rapidly 19.6 (10) 31.4 (16) 41.2 (21) 5.9 (3) 2.0 (1) progressive alopecia areata Oral isotretinoin for nodulocystic or 90.2 (46) 9.8 (5) 0.0 (0) 0.0 (0) 0.0 (0) recalcitrant acne vulgaris in teenagers Initiating phototherapy orders for a 47.1 (24) 29.4 (15) 15.7 (8) 7.8 (4) 0.0 (0) pediatric patient Managing a pediatric patient with patch 7.8 (4) 39.2 (20) 33.3 (17) 17.6 (9) 2.0 (1) or plaque-stage mycosis fungoides Managing a pediatric patient with eczema 68.6 (35) 25.5 (13) 5.9 (3) 0.0 (0) 0.0 (0) herpeticum Patch testing a child or adolescent 49.0 (25) 39.2 (20) 7.8 (4) 2.0 (1) 2.0 (1) Pulsed dye laser therapy for vascular 27.5 (14) 35.3 (18) 21.6 (11) 15.7 (8) 0.0 (0) birthmarks in a child Please detail your comfort level in INDEPENDENTLY working up and managing pediatric patients with the following conditions Atopic dermatitis of infancy 94.1 (48) 5.9 (3) 0.0 (0) 0.0 (0) 0.0 (0) Localized scalp psoriasis 92.2 (47) 5.9 (3) 2.0 (1) 0.0 (0) 0.0 (0) Erythrodermic psoriasis 19.6 (10) 56.9 (29) 13.7 (7) 9.8 (5) 0.0 (0) Eczema herpeticum 68.6 (35) 27.5 (14) 2.0 (1) 2.0 (1) 0.0 (0) Patch or plaque-state mycosis fungoides 13.7 (7) 31.4 (16) 35.3 (18) 13.7 (7) 5.9 (3) Tinea capitis 90.2 (46) 5.9 (3) 3.9 (2) 0.0 (0) 0.0 (0) Molluscum 100.0 (51) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) Warts 100.0 (51) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) Netherton’s syndrome 7.8 (4) 45.1 (23) 25.5 (13) 17.6 (9) 3.9 (2) Congenital ichthyoses (epidermolytic 9.8 (5) 41.2 (21) 31.4 (16) 17.6 (9) 0.0 (0) hyperkeratosis, X-linked) Congenital blistering conditions 13.7 (7) 29.4 (15) 29.4 (15) 17.6 (9) 9.8 (5) (epidermolysis bullosa) Disorders with increased risk of 5.9 (3) 43.1 (22) 23.5 (12) 25.5 (13) 2.0 (1) malignancy (xeroderma pigmentosum, Rothmund-Thomson, Gorlin syndrome) Please detail your comfort level performing procedures on infants and children (any age): [% (n)] Punch biopsy 82.4 (42) 11.8 (6) 3.9 (2) 2.0 (1) 0.0 (0) Shave biopsy or tangential biopsy 82.4 (42) 11.8 (6) 5.9 (3) 0.0 (0) 0.0 (0) Excision 54.9 (28) 29.4 (15) 7.8 (4) 5.9 (3) 2.0 (1) Patch testing 49.0 (25) 35.3 (18) 9.8 (5) 3.9 (2) 2.0 (1) Intralesional injections 84.3 (43) 15.7 (8) 0.0 (0) 0.0 (0) 0.0 (0) Pulsed-dye laser 35.3 (18) 41.2 (21) 17.6 (9) 3.9 (2) 2.0 (1) Excimer light source 19.6 (10) 31.4 (16) 25.5 (13) 15.7 (8) 7.8 (4) Cryotherapy of warts 96.1 (49) 3.9 (2) 0.0 (0) 0.0 (0) 0.0 (0)
residents were satisfied with their training curriculum, 25.5% felt neutral or were dissatisfied with their education. Residents in programs with no full-time pediatric dermatologist were the only residents who were somewhat or extremely dissatisfied with their pediatric training (p < 0.05). Residents were satisfied with their pediatric dermatology training even with just one pediatric dermatologist (p < 0.05).
RPDs were also more likely to be more satisfied with their curriculums with one or more pediatric dermatologist (p < 0.01). Residents in programs with pediatric dermatology fellowships were much more likely to report being extremely satisfied than residents in programs without pediatric dermatology fellowships (68.2% vs 31.8%, p < 0.001). RPDs in programs with fellowships were also more likely to report being
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TABLE 4. Expectation and Satisfaction with Pediatric Dermatology Training Graduating residents, % (n)
Residency directors, % (n)
Expectation of pediatric dermatology training during residency in how residents should feel postresidency Confidently treat almost ALL pediatric diseases 19.6 (10) 55.6 (25) Confidently treat MOST pediatric diseases 68.6 (35) 40.0 (18) Confidently treat only more common/basic pediatric diseases 9.8 (5) 4.4 (2) Refer out most of their pediatric patients 2.0 (1) 0 (0) Satisfaction with your residency program’s pediatric dermatology curriculum Extremely satisfied 43.1 (22) 51.1 (23) Somewhat satisfied 31.4 (16) 28.9 (13) Neutral 9.8 (5) 6.7 (3) Somewhat dissatisfied 9.8 (5) 13.3 (6) Extremely dissatisfied 5.9 (3) 0 (0) How competent do you feel in INDEPENDENTLY managing pediatric patients once you graduate from residency? Very competent 35.3 (18) N/A Somewhat competent 56.9 (29) Not very competent 5.9 (3) Not competent at all 0 (0) Will likely refer most pediatric patients out 2.0 (1)
extremely satisfied with their curriculum (84.6% vs 37.5%, p < 0.04). Programs with pediatric-specific lectures and kodachrome reviews had a greater percentage of GRs who felt extremely or somewhat satisfied with their curriculum than of those without these specific lectures (78.4% vs 64.3%, p = 0.03), and RPDs noted the results as well (85.4% vs 25%, p = 0.02). A greater percentage of GRs in programs with a pediatric dermatology–specific rotation reported being more satisfied with their curriculum than those in programs without a specific pediatric rotation (80.8% vs 68.0%, p = 0.27); although not statistically significant among residents, this notion was statistically significant among RPDs (p < 0.002) and FPDs (p = 0.05). GRs without a separate clinic for pediatric patients were much more likely to be dissatisfied with their curriculum (55.6% vs 7.1%, p < 0.001) than GRs with as little as 0.5 days of pediatric dermatology clinic a month. RPDs similarly noted this sentiment (p = 0.01). FPDs were more satisfied with at least 2 half days of clinic per month (p = 0.02). RPDs and FPDs were asked about their expectations for residents with regard to their pediatric training. Although 56% of RPDs hoped that their residents would treat almost all pediatric diseases, only 12% of FPDs selected this choice, with 82% of FPDs hoping the residents would treat most pediatric diseases. When asked about their satisfaction with their program’s pediatric dermatology curriculum, 51% of RPDs and 59% of FPDs were extremely satisfied, although 19% of RPDs were neutral or dissatisfied and 6% of FPDs were dissatisfied.
Fellowship directors, % (n) 11.8 (2) 82.4 (14) 5.9 (1) 0 (0) 58.8 (10) 35.3 (6) 0 (0) 5.9 (1) 0 (0) N/A
DISCUSSION This survey highlights that the presence of a full-time pediatric dermatologist globally improves the core pediatric dermatology training in residency. The effect that the presence of even one full-time pediatric dermatologist has on resident satisfaction and selfrated competence is notable. One-third (33.3%) of GRs and 43.1% of RPDs responded that they had no full-time pediatric dermatologist on staff, and 71.4% and 59.1% of those, respectively, also had no part-time pediatric dermatologist. There is a clear discrepancy, with some programs reporting more than four full-time pediatric dermatologists at their respective institutions. Further studies need to assess and address barriers to expansion of the pediatric dermatology workforce, including length of education and lower pay than for general dermatology (8–10). With regard to didactic education, although all respondents felt that pediatric dermatology made up 11% to 14% of didactic time, RPDs and FPDs felt that more than twice the number of hours per month was being spent on pediatric-specific lectures and kodachromes than the approximate hours residents felt they received. With experts in pediatric dermatology at their institutions, programs are much more likely to have journal clubs and didactic sessions that are pediatrics focused (p < 0.001); 52.8% and 91.7% of programs with at least one pediatric dermatologist had focused journal clubs and didactic sessions, respectively, and 71.4% of programs with two or more pediatric dermatologists had journal clubs.
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Pediatric dermatology–specific rotations are more common in programs with fellowships (73.7%), and there is greater satisfaction at these programs. Furthermore, the data suggest that the presence of two or more pediatric dermatologists enhances residency education through greater didactic sessions and expansion of pediatrics-specific rotations. Programs with at least one full-time pediatric dermatologist had pediatrics-specific rotations 69.4% of the time, while programs with at least two full-time pediatric dermatologists had specific rotations 81.0% of the time. In their comments, RPDs and FPDs felt that stronger training was delivered when given in specific continuous rotations than with scattered time throughout one’s residency. Residencies without pediatrics-specific rotations may benefit from implementing this change, similar to how residents are assigned surgical rotations (3). GRs with pediatric dermatology attendings generally felt more comfortable using various treatment modalities. For example, 79.4% of GRs with one or more pediatric dermatology attending on staff felt somewhat or very comfortable prescribing oral propranolol for infantile hemangiomas, compared with 47.1% of GR with no full-time pediatric dermatologist on staff (p < 0.002). There are clear limitations to this study, including incomplete responses from all three study groups. The response rate of 15.8% of graduating third-year residents may be underestimated because program coordinators forwarded the survey links to the residents and there is no way to make certain that all residents received this survey. Additionally, although individual responses may be biased, and some dermatology programs may not be represented in any of the respondent groups, overall there was representation by all types of programs, with varying numbers of pediatric dermatologists on staff in diverse geographic regions. We feel that the results from this survey support the need for dermatology residency programs to continue to strengthen their pediatric dermatology curriculums, especially in programs without a pediatric
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dermatologist. Pediatric dermatology education can be increased with expansion of pediatric dermatology resident clinics, encouragement of a greater number of didactic sessions, and inclusion of pediatrics-specific rotations. Ultimately the cultivation and recruitment of pediatric dermatologists at academic teaching institutions will be required to provide enhanced pediatric dermatology training across the country. REFERENCES 1. Schachner LA, Hansen RG. Preface. In: Schachner LA, Hansen RC, eds. Pediatric dermatology, 2nd ed. New York: Churchill-Livingstone, 1995:ix. 2. Craiglow BG, Resneck JS Jr, Lucky AW et al. Pediatric dermatology workforce shortage: perspectives from academia. J Am Acad Dermatol 2008;59:986–989. 3. Hester EJ, McNealy KM, Kelloff JN et al. Demand outstrips supply of US pediatric dermatologists: results from a national survey. J Am Acad Dermatol 2004; 50:431–434. 4. Lee EH, Nehal KS, Dusza SW et al. Procedural dermatology training during dermatology residency: a survey of third-year dermatology residents. J Am Acad Dermatol 2011;64:475–483, e1–e5. 5. High WA, Cruz PD Jr. Contact dermatitis education in dermatology residency programs: can (will) the American Contact Dermatitis Society be a force for improvement? Am J Contact Dermat 2003;14:195–199. 6. Singh S, Grummer SE, Hancox JG et al. The extent of dermatopathology education: a comparison of pathology and dermatology. J Am Acad Dermatol 2005; 53:694–697. 7. Nijhawan RI, Jacob SE, Woolery-Lloyd H. Skin of color education in dermatology residency programs: does residency training reflect the changing demographics of the United States? J Am Acad Dermatol 2008;59:615–618. 8. Hinshaw M, Hsu P, Lee LY et al. The current state of dermatopathology education: a survey of the Association of Professors of Dermatology. J Cutan Pathol 2009;36:620–628. 9. Society for Pediatric Dermatology. Average salary for peds derm exceeds $225K in 2011: increase of 10% since 2008. SPD Rev. 2011;6:1, 4–6. 10. Kane L. Dermatologist compensation report 2012 [online]. http://www.medscape.com/features/slideshow/ compensation/2012/dermatology. Accessed on May 7, 2013.
Pediatric Dermatology Training Survey of United States Dermatology Residency Programs Rajiv I. Nijhawan, M.D., Joni M. Mazza, M.D., and Nanette B. Silverberg, M.D. Department of Dermatology, St. Luke’s-Roosevelt and Beth Israel Medical Centers, New York City, New York
Abstract: Variability exists in pediatric dermatology education for dermatology residents. We sought to formally assess the pediatric dermatology curriculum and experience in a dermatology residency program. Three unique surveys were developed for dermatology residents, residency program directors, and pediatric dermatology fellowship program directors. The surveys consisted of questions pertaining to residency program characteristics. Sixty-three graduating third-year residents, 51 residency program directors, and 18 pediatric dermatology fellowship program directors responded. Residents in programs with one or more full-time pediatric dermatologist were more likely to feel very competent treating children and were more likely to be somewhat or extremely satisfied with their pediatric curriculums than residents in programs with no full-time pediatric dermatologist (50.0% vs 5.9%, p = 0.002, and 85.3% vs 52.9%, p < 0.001, respectively). Residents in programs with no full-time pediatric dermatologist were the only residents who were somewhat or extremely dissatisfied with their pediatric training. Residency program directors were more satisfied with their curriculums when there was one or more pediatric dermatologist on staff (p < 0.01). Residents in programs with pediatric dermatology fellowships were much more likely to report being extremely satisfied than residents in programs without a pediatric dermatology fellowship (83.3% vs 21.2%; p < 0.001). The results of this survey support the need for dermatology residency programs to continue to strengthen their pediatric dermatology curriculums, especially through the recruitment of full-time pediatric dermatologists.
Pediatric dermatology is an important component of the core curriculum of dermatology residency training. It is estimated that 30% of dermatology office visits are for children, so it is essential that dermatologists have a certain degree of competence and confidence in pediatric dermatology (1,2).
Considerable variability exists in the type and extent of pediatric dermatology education that residents receive nationally. Factors such as geographic location, patient population, number of pediatric didactic sessions, and presence of a full-time pediatric dermatologist are all variables during training.
Address correspondence to Joni M. Mazza, M.D., Department of Dermatology, St. Luke’s-Roosevelt and Beth Israel Medical Centers, 1090 Amsterdam Avenue, Suite 11B, New York, NY 10023, or e-mail: [email protected]. DOI: 10.1111/pde.12266
© 2013 Wiley Periodicals, Inc.
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Previous studies have reported a national shortage of pediatric dermatologists at academic training centers and in clinical practice (1,2). Whereas other dermatologic subspecialities such as procedural dermatology, dermatopathology, contact dermatitis, and skin-of-color education have been formally assessed in the context of residency training (3–7), to our knowledge no previous study has formally assessed pediatric dermatology curriculums and experiences in dermatology residency programs.
METHODS Study Population and Survey Methodology
expectations and satisfaction with pediatric dermatology training in dermatology residency programs. All responses were collected anonymously. Statistical Analysis Descriptive frequencies, medians, and means were calculated to describe survey responses. Chi-square statistics were calculated to assess the independence of study variables. RESULTS Sixty-three graduating third-year residents out of 399 nationwide (response rate 15.8%), 51 residency program directors (response rate 45.5%), and 18 pediatric dermatology fellowship program directors (response rate 62.1%) responded. The mean age of graduating resident respondents was 32.4 years (range 28–44 years). The residency program characteristics of the respondents, including children’s hospital and pediatric dermatology fellowship affiliations, are detailed in Table 1.
One hundred fourteen Accreditation Council for Graduate Medical Education (ACGME)-approved dermatology residency programs and their respective program directors were identified using the ACGME website (https://www.acgme.org/ads/Public/Reports/ Report/1, accessed May 10, 2012). Two programs that did not have any third-year residents were excluded from the study. Twenty-nine pediatric dermatology fellowship directors recognized by the American Board of Dermatology (ABD) were identified in July 2012 using the ABD website (http://www.abderm.org/subspecialties/ped_derm_programs.pdf, accessed June 7, 2012). The authors developed three separate, unique surveys addressing pediatric dermatology education that were posted using an independent online host (http://www.surveymonkey.com) for the study groups: third-year residents graduating in June 2012 (GRs), dermatology residency program directors (RPDs) (n = 112), and pediatric dermatology fellowship program directors (FPDs) (n = 29). A link to the relevant survey was e-mailed to the respective targeted study groups. E-mail addresses were compiled for 127 GRs from 38 programs and the remaining 74 program coordinators requested that the link to the survey be forwarded to the GRs by the program coordinator directly. The study groups were e-mailed monthly from June to August 2012.
Table 2 details clinical training specific to pediatric dermatology. Residents receive the vast majority of their pediatric dermatology clinical training in resident clinics, accounting for 70.1% of their pediatric dermatology exposure. According to the RPDs, 56.5% of dermatology residency programs have pediatric-specific clinics, the percentage being much greater at programs with fellowships (76.9%, p = 0.08). When they are in a resident clinic, 62.3% of GRs reported that they are the primary provider for patients. Approximately half of residency programs nationally have pediatric dermatology–specific rotations, although according to RPDs, residencies with a fellowship program at their respective institutions are more likely to have dedicated rotations (69.2% vs 42.4%, p = 0.10). The range reported of required time spent on this rotation throughout 3 years of residency varied from 8 to 16 weeks.
Survey Content
Didactic Education
The surveys (Tables S1–S3) consisted of questions pertaining to residency program characteristics, type and extent of clinical exposure to pediatric dermatology, amount of didactic time dedicated specifically to this subspecialty, residents’ perceived comfort level and confidence in independently managing conditions more prevalent in pediatric populations, and overall
Table 2 details didactic sessions. All three groups of respondents reported a range of 10.8% to 13.8% with regard to the percentage of pediatric dermatology didactic time. Although RPDs and FPDs felt that GRs had 4.6 and 4.9 hours, respectively, of pediatric dermatology didactic time per month, GRs reported receiving 2.3 hours per month. According
Clinical Training
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TABLE 1. Residency Program Characteristics Dermatology residents n
%
Residency directors n
Fellowship directors %
Sex Male 27 42.9 N/A N/A Female 36 57.1 Region of United States Northeast 25 39.7 15 29.4 Southeast 6 9.5 7 13.7 Midwest 20 31.7 14 27.5 South 4 6.3 7 13.7 Southwest 1 1.6 2 3.9 West 7 11.1 6 11.8 ≤5 miles from a major urban city Yes 54 85.7 34 66.7 No 9 14.3 17 33.3 Medical school affiliation Yes 61 96.8 50 98.0 No 2 3.2 1 2.0 Children’s hospital affiliation Yes 42 66.7 45 88.2 No 21 33.3 6 11.8 Pediatrics residency program Yes 56 88.9 48 94.1 No 7 11.1 3 5.9 Number of full-time pediatric dermatologists on staff 0 21 33.3 22 43.1 1 16 25.4 12 23.5 2 12 19.0 9 17.6 3 4 6.3 4 7.8 4 1 1.6 1 2.0 >4 9 14.3 3 5.9 Number of part-time pediatric dermatologists on staff (if answered “0” to previous question) 0 15 71.4 13 59.1 1 6 28.6 9 40.9 Pediatric dermatology fellowship Yes 19 35.8 15 29.4 No 34 64.2 36 70.6 Plan for program to apply for a fellowship in next 2 years Yes N/A N/A 3 8.3 No 33 91.7 Will you be completing a pediatric dermatology fellowship next year? Yes 3 5.9 N/A N/A No 48 94.1
to GRs, programs with a pediatric dermatology fellowship were more likely to have pediatric specific rotations (73.7% vs 41.2%, p = 0.02), didactic lectures (89.5% vs 61.8%, p = 0.03), and pediatric journal review (73.7% vs 14.7%, p < 0.001). The most commonly reviewed pediatric-specific textbooks according to GRs, RPDs, and FPDs are listed in Table 2. Of note, 39.6% of GRs reported not reviewing any pediatric dermatology-specific text, compared with 15.2% of RPDs and 23.5% of FPDs. Resident Comfort Levels GRs were asked to rate their comfort level in independently managing various pediatric dermato-
n
%
N/A
N/A
5 2 6 1 1 3
27.8 11.1 33.3 5.6 5.6 16.7
15 3
83.3 16.7
17 1
94.4 5.6
18 0
100 0
17 1
94.4 5.6
0 2 7 3 1 5
0 11.1 38.9 16.7 5.6 27.8
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
logic conditions and the use of systemic medications, phototherapy and lasers in children (Table 3). More than 90% of GRs felt very comfortable treating patients with atopic dermatitis (94.1%), scalp psoriasis (92.2%), and tinea capitis (90.2%), but comfort levels decreased for more challenging conditions, such as mycosis fungoides (13.7%) and disorders with a high risk of malignancy (5.9%). Residents’ Perception of Competency GRs were asked questions on their self-perception of their competence in independently managing pediatric patients (Table 4). The majority of third-year residents (56.9%) felt only somewhat competent in independently managing pediatric patients once they
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TABLE 2. Resident Clinical and Didactic Exposure Dermatology residents, % (n) Pediatric dermatology clinical exposure setting Resident clinic 70.1 Private practice 17.6 Inpatient consult service 16.2 Fellow clinic 1.0 External rotations 5.8 Clinics exclusive for pediatric patients or mixed with adults Exclusive (only pediatric) 69.8 (37) Mixed (pediatric and adult) 30.2 (16) Residents’ role in managing pediatric dermatology patients (check all applicable) Primary provider in resident/fellow clinic 62.3 Primary provider in private clinic 39.6 Assist attending in private clinic 24.5 Frequency that resident is assigned to work in pediatric dermatology clinic No separate clinic for pediatric patients 17.6 (9) ~1 half-day clinic per month 21.6 (11) ~2 half-day clinics per month 11.8 (6) ~3 half-day clinics per month 17.6 (9) ~1 half-day clinic per week 15.7 (8) ~2 half-day clinics per week 15.7 (8) Pediatric dermatology–specific rotation Yes 52.8 (28) No 47.2 (25) Amount of resident education dedicated to pediatric dermatology % 10.8 Hours per month 2.3 Pediatric dermatology journal club Yes 35.8 (18) No 64.2 (34) Pediatric dermatology–specific lectures and kodachromes Yes 71.7 (38) No 28.3 (15) Textbooks None 39.6 (21) Color Atlas and Synopsis of Pediatric Dermatology (eds. Kane, Lio, 1.9 (1) Stratigos, and Johnson) Color Textbook of Pediatric Dermatology (eds. Weston, Lane, and 0 (0) Morelli) Harper’s Textbook of Pediatric Dermatology (eds. Irvine, Hoeger, 0 (0) and Yan) Hurwitz Clinical Pediatric Dermatology (eds. Paller and Mancini) 22.6 (12) Pediatric Dermatology (eds. Schachner and Hansen) 5.7 (3) Pediatric Dermatology: Requisites in Dermatology (eds. Pride, Yan 1.9 (1) and Zaenglein) Genodermatoses: A Clinical Guide to Genetic Disorders (ed. Spitz) 50.9 (27) Textbook of Pediatric Dermatology (eds. Harper, Oranje, and Prose) 1.9 (1) Other 1.9 (1)
graduate from residency. Residents who received pediatric-specific lectures or kodachromes (reviews of visual images of skin conditions) were more likely to feel very competent than those who did not receive these sessions (88.9 vs 11.1%, p = 0.08). GRs with separate pediatric clinics even just 0.5 days per month were much more likely to feel very competent in treating children (p = 0.03) than those who saw children in a mixed adult and pediatric clinic. GRs with a pediatric dermatology fellowship at their programs were more likely to feel very competent (55.6%) than residents in a program without a
Residency directors, % (n)
Fellowship directors, % (n)
71.5 19.4 11.6 3.3 6.6
66.7 28.2 13.5 5.0 0.7
56.5 (26) 43.5 (20)
94.1 (16) 5.9 (1)
54.3 47.3 28.3
47.1 35.3 58.8
22.2 (10) 15.6 (7) 17.8 (8) 4.4 (2) 31.1 (14) 8.9 (4)
0 (0) 11.8 (2) 11.8 (2) 17.6 (3) 47.1 (8) 11.8 (2)
50 (23) 50 (23)
82.4 (14) 17.6 (3)
11.4 4.6
13.8 4.9
52.2 (24) 47.8 (22)
76.5 (13) 23.5 (4)
91.3 (42) 8.7 (4)
100 (17) 0 (0)
15.2 (7) 6.5 (3)
23.5 (4) 0 (0)
17.4 (8)
17.6 (3)
4.3 (2)
5.9 (1)
60.9 (28) 17.4 (8) 2.2 (1)
70.6 (12) 17.6 (3) 0 (0)
69.6 (32) 15.2 (7) 6.5 (3)
35.3 (6) 17.6 (3) 11.8 (2)
fellowship (24.2%, p = 0.05). In addition, those who felt extremely satisfied with their pediatric dermatology program were much more likely to feel very competent in independently treating patients after residency (p < 0.001). Pediatric Dermatology Curriculum Expectations and Satisfaction GRs, RPDs, and FPDs were asked questions on pediatric dermatology curriculum expectations and satisfaction (Table 4). Although the majority of
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TABLE 3. Resident Comfort Level in Management and Procedures Very comfortable, % (n)
Somewhat comfortable, % (n)
Not very comfortable, % (n)
Not comfortable at all, % (n)
Would not use this treatment for disease or perform on a pediatric patient, % (n)
On the following scale, please rate your comfort level in INDEPENDENTLY starting a pediatric patient at any age (including newborns, infants, and children) on one of the following systemic medications Oral propranolol in the inpatient or 29.4 (15) 39.2 (20) 21.6 (11) 9.8 (5) 0.0 (0) outpatient setting for an infantile hemangioma Oral prednisone in the outpatient setting 54.9 (28) 37.3 (19) 7.8 (4) 0.0 (0) 0.0 (0) for poison ivy in a child Oral methotrexate in the outpatient 23.5 (12) 49.0 (25) 23.5 (12) 2.9 (2) 0.0 (0) setting for morphea/scleroderma Subcutaneous biologic therapy (e.g., 27.5 (14) 47.1 (24) 17.6 (9) 7.8 (9) 0.0 (0) etanercept, adalimumab) for pediatric or adolescent psoriasis Pulsed oral prednisone for rapidly 19.6 (10) 31.4 (16) 41.2 (21) 5.9 (3) 2.0 (1) progressive alopecia areata Oral isotretinoin for nodulocystic or 90.2 (46) 9.8 (5) 0.0 (0) 0.0 (0) 0.0 (0) recalcitrant acne vulgaris in teenagers Initiating phototherapy orders for a 47.1 (24) 29.4 (15) 15.7 (8) 7.8 (4) 0.0 (0) pediatric patient Managing a pediatric patient with patch 7.8 (4) 39.2 (20) 33.3 (17) 17.6 (9) 2.0 (1) or plaque-stage mycosis fungoides Managing a pediatric patient with eczema 68.6 (35) 25.5 (13) 5.9 (3) 0.0 (0) 0.0 (0) herpeticum Patch testing a child or adolescent 49.0 (25) 39.2 (20) 7.8 (4) 2.0 (1) 2.0 (1) Pulsed dye laser therapy for vascular 27.5 (14) 35.3 (18) 21.6 (11) 15.7 (8) 0.0 (0) birthmarks in a child Please detail your comfort level in INDEPENDENTLY working up and managing pediatric patients with the following conditions Atopic dermatitis of infancy 94.1 (48) 5.9 (3) 0.0 (0) 0.0 (0) 0.0 (0) Localized scalp psoriasis 92.2 (47) 5.9 (3) 2.0 (1) 0.0 (0) 0.0 (0) Erythrodermic psoriasis 19.6 (10) 56.9 (29) 13.7 (7) 9.8 (5) 0.0 (0) Eczema herpeticum 68.6 (35) 27.5 (14) 2.0 (1) 2.0 (1) 0.0 (0) Patch or plaque-state mycosis fungoides 13.7 (7) 31.4 (16) 35.3 (18) 13.7 (7) 5.9 (3) Tinea capitis 90.2 (46) 5.9 (3) 3.9 (2) 0.0 (0) 0.0 (0) Molluscum 100.0 (51) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) Warts 100.0 (51) 0.0 (0) 0.0 (0) 0.0 (0) 0.0 (0) Netherton’s syndrome 7.8 (4) 45.1 (23) 25.5 (13) 17.6 (9) 3.9 (2) Congenital ichthyoses (epidermolytic 9.8 (5) 41.2 (21) 31.4 (16) 17.6 (9) 0.0 (0) hyperkeratosis, X-linked) Congenital blistering conditions 13.7 (7) 29.4 (15) 29.4 (15) 17.6 (9) 9.8 (5) (epidermolysis bullosa) Disorders with increased risk of 5.9 (3) 43.1 (22) 23.5 (12) 25.5 (13) 2.0 (1) malignancy (xeroderma pigmentosum, Rothmund-Thomson, Gorlin syndrome) Please detail your comfort level performing procedures on infants and children (any age): [% (n)] Punch biopsy 82.4 (42) 11.8 (6) 3.9 (2) 2.0 (1) 0.0 (0) Shave biopsy or tangential biopsy 82.4 (42) 11.8 (6) 5.9 (3) 0.0 (0) 0.0 (0) Excision 54.9 (28) 29.4 (15) 7.8 (4) 5.9 (3) 2.0 (1) Patch testing 49.0 (25) 35.3 (18) 9.8 (5) 3.9 (2) 2.0 (1) Intralesional injections 84.3 (43) 15.7 (8) 0.0 (0) 0.0 (0) 0.0 (0) Pulsed-dye laser 35.3 (18) 41.2 (21) 17.6 (9) 3.9 (2) 2.0 (1) Excimer light source 19.6 (10) 31.4 (16) 25.5 (13) 15.7 (8) 7.8 (4) Cryotherapy of warts 96.1 (49) 3.9 (2) 0.0 (0) 0.0 (0) 0.0 (0)
residents were satisfied with their training curriculum, 25.5% felt neutral or were dissatisfied with their education. Residents in programs with no full-time pediatric dermatologist were the only residents who were somewhat or extremely dissatisfied with their pediatric training (p < 0.05). Residents were satisfied with their pediatric dermatology training even with just one pediatric dermatologist (p < 0.05).
RPDs were also more likely to be more satisfied with their curriculums with one or more pediatric dermatologist (p < 0.01). Residents in programs with pediatric dermatology fellowships were much more likely to report being extremely satisfied than residents in programs without pediatric dermatology fellowships (68.2% vs 31.8%, p < 0.001). RPDs in programs with fellowships were also more likely to report being
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TABLE 4. Expectation and Satisfaction with Pediatric Dermatology Training Graduating residents, % (n)
Residency directors, % (n)
Expectation of pediatric dermatology training during residency in how residents should feel postresidency Confidently treat almost ALL pediatric diseases 19.6 (10) 55.6 (25) Confidently treat MOST pediatric diseases 68.6 (35) 40.0 (18) Confidently treat only more common/basic pediatric diseases 9.8 (5) 4.4 (2) Refer out most of their pediatric patients 2.0 (1) 0 (0) Satisfaction with your residency program’s pediatric dermatology curriculum Extremely satisfied 43.1 (22) 51.1 (23) Somewhat satisfied 31.4 (16) 28.9 (13) Neutral 9.8 (5) 6.7 (3) Somewhat dissatisfied 9.8 (5) 13.3 (6) Extremely dissatisfied 5.9 (3) 0 (0) How competent do you feel in INDEPENDENTLY managing pediatric patients once you graduate from residency? Very competent 35.3 (18) N/A Somewhat competent 56.9 (29) Not very competent 5.9 (3) Not competent at all 0 (0) Will likely refer most pediatric patients out 2.0 (1)
extremely satisfied with their curriculum (84.6% vs 37.5%, p < 0.04). Programs with pediatric-specific lectures and kodachrome reviews had a greater percentage of GRs who felt extremely or somewhat satisfied with their curriculum than of those without these specific lectures (78.4% vs 64.3%, p = 0.03), and RPDs noted the results as well (85.4% vs 25%, p = 0.02). A greater percentage of GRs in programs with a pediatric dermatology–specific rotation reported being more satisfied with their curriculum than those in programs without a specific pediatric rotation (80.8% vs 68.0%, p = 0.27); although not statistically significant among residents, this notion was statistically significant among RPDs (p < 0.002) and FPDs (p = 0.05). GRs without a separate clinic for pediatric patients were much more likely to be dissatisfied with their curriculum (55.6% vs 7.1%, p < 0.001) than GRs with as little as 0.5 days of pediatric dermatology clinic a month. RPDs similarly noted this sentiment (p = 0.01). FPDs were more satisfied with at least 2 half days of clinic per month (p = 0.02). RPDs and FPDs were asked about their expectations for residents with regard to their pediatric training. Although 56% of RPDs hoped that their residents would treat almost all pediatric diseases, only 12% of FPDs selected this choice, with 82% of FPDs hoping the residents would treat most pediatric diseases. When asked about their satisfaction with their program’s pediatric dermatology curriculum, 51% of RPDs and 59% of FPDs were extremely satisfied, although 19% of RPDs were neutral or dissatisfied and 6% of FPDs were dissatisfied.
Fellowship directors, % (n) 11.8 (2) 82.4 (14) 5.9 (1) 0 (0) 58.8 (10) 35.3 (6) 0 (0) 5.9 (1) 0 (0) N/A
DISCUSSION This survey highlights that the presence of a full-time pediatric dermatologist globally improves the core pediatric dermatology training in residency. The effect that the presence of even one full-time pediatric dermatologist has on resident satisfaction and selfrated competence is notable. One-third (33.3%) of GRs and 43.1% of RPDs responded that they had no full-time pediatric dermatologist on staff, and 71.4% and 59.1% of those, respectively, also had no part-time pediatric dermatologist. There is a clear discrepancy, with some programs reporting more than four full-time pediatric dermatologists at their respective institutions. Further studies need to assess and address barriers to expansion of the pediatric dermatology workforce, including length of education and lower pay than for general dermatology (8–10). With regard to didactic education, although all respondents felt that pediatric dermatology made up 11% to 14% of didactic time, RPDs and FPDs felt that more than twice the number of hours per month was being spent on pediatric-specific lectures and kodachromes than the approximate hours residents felt they received. With experts in pediatric dermatology at their institutions, programs are much more likely to have journal clubs and didactic sessions that are pediatrics focused (p < 0.001); 52.8% and 91.7% of programs with at least one pediatric dermatologist had focused journal clubs and didactic sessions, respectively, and 71.4% of programs with two or more pediatric dermatologists had journal clubs.
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Pediatric dermatology–specific rotations are more common in programs with fellowships (73.7%), and there is greater satisfaction at these programs. Furthermore, the data suggest that the presence of two or more pediatric dermatologists enhances residency education through greater didactic sessions and expansion of pediatrics-specific rotations. Programs with at least one full-time pediatric dermatologist had pediatrics-specific rotations 69.4% of the time, while programs with at least two full-time pediatric dermatologists had specific rotations 81.0% of the time. In their comments, RPDs and FPDs felt that stronger training was delivered when given in specific continuous rotations than with scattered time throughout one’s residency. Residencies without pediatrics-specific rotations may benefit from implementing this change, similar to how residents are assigned surgical rotations (3). GRs with pediatric dermatology attendings generally felt more comfortable using various treatment modalities. For example, 79.4% of GRs with one or more pediatric dermatology attending on staff felt somewhat or very comfortable prescribing oral propranolol for infantile hemangiomas, compared with 47.1% of GR with no full-time pediatric dermatologist on staff (p < 0.002). There are clear limitations to this study, including incomplete responses from all three study groups. The response rate of 15.8% of graduating third-year residents may be underestimated because program coordinators forwarded the survey links to the residents and there is no way to make certain that all residents received this survey. Additionally, although individual responses may be biased, and some dermatology programs may not be represented in any of the respondent groups, overall there was representation by all types of programs, with varying numbers of pediatric dermatologists on staff in diverse geographic regions. We feel that the results from this survey support the need for dermatology residency programs to continue to strengthen their pediatric dermatology curriculums, especially in programs without a pediatric
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dermatologist. Pediatric dermatology education can be increased with expansion of pediatric dermatology resident clinics, encouragement of a greater number of didactic sessions, and inclusion of pediatrics-specific rotations. Ultimately the cultivation and recruitment of pediatric dermatologists at academic teaching institutions will be required to provide enhanced pediatric dermatology training across the country. REFERENCES 1. Schachner LA, Hansen RG. Preface. In: Schachner LA, Hansen RC, eds. Pediatric dermatology, 2nd ed. New York: Churchill-Livingstone, 1995:ix. 2. Craiglow BG, Resneck JS Jr, Lucky AW et al. Pediatric dermatology workforce shortage: perspectives from academia. J Am Acad Dermatol 2008;59:986–989. 3. Hester EJ, McNealy KM, Kelloff JN et al. Demand outstrips supply of US pediatric dermatologists: results from a national survey. J Am Acad Dermatol 2004; 50:431–434. 4. Lee EH, Nehal KS, Dusza SW et al. Procedural dermatology training during dermatology residency: a survey of third-year dermatology residents. J Am Acad Dermatol 2011;64:475–483, e1–e5. 5. High WA, Cruz PD Jr. Contact dermatitis education in dermatology residency programs: can (will) the American Contact Dermatitis Society be a force for improvement? Am J Contact Dermat 2003;14:195–199. 6. Singh S, Grummer SE, Hancox JG et al. The extent of dermatopathology education: a comparison of pathology and dermatology. J Am Acad Dermatol 2005; 53:694–697. 7. Nijhawan RI, Jacob SE, Woolery-Lloyd H. Skin of color education in dermatology residency programs: does residency training reflect the changing demographics of the United States? J Am Acad Dermatol 2008;59:615–618. 8. Hinshaw M, Hsu P, Lee LY et al. The current state of dermatopathology education: a survey of the Association of Professors of Dermatology. J Cutan Pathol 2009;36:620–628. 9. Society for Pediatric Dermatology. Average salary for peds derm exceeds $225K in 2011: increase of 10% since 2008. SPD Rev. 2011;6:1, 4–6. 10. Kane L. Dermatologist compensation report 2012 [online]. http://www.medscape.com/features/slideshow/ compensation/2012/dermatology. Accessed on May 7, 2013.
