Jules B. Lipoff

Smartphones, photography, and security in dermatology

REFERENCES 1. Chaudhry SB, Armbrecht ES, Shin Y, et al. Pediatric access to dermatologists: Medicaid versus private insurance. J Am Acad Dermatol. 2013;68:738-748. 2. Resneck JS Jr, Isenstein A, Kimball AB. Few Medicaid and uninsured patients are accessing dermatologists. J Am Acad Dermatol. 2006;55:1084-1088. 3. Bisgaier J, Rhodes KV. Auditing access to specialty care for children with public insurance. N Engl J Med. 2011;364: 2324-2333. 4. Rosenthal E. Patients’ costs skyrocket; specialists’ incomes soar. New York Times. Available from: http://www.nytimes. com/2014/01/19/health/patients-costs-skyrocket-specialistsincomes-soar.html?_r1⁄40. Accessed June 1, 2014. 5. American Board of Medical Specialties. Certification matters: is your doctor board certified? Available from: http://www. certificationmatters.org/is-your-doctor-board-certified.aspx. Accessed May 1, 2013.

Feasibility and cost of a medical student proxy-based mobile teledermatology consult service with Kisoro, Uganda, and Lake Atitlán, Guatemala

The expansion of mobile technology and coverage has unveiled new means for delivering medical care to isolated and resource‐poor communities. Teledermatology, or dermatology consultation from a distance using technology, is gaining greater acceptance among physicians and patients.

The Africa Teledermatology Project: A retrospective case review of 1229 consultations from sub-Saharan Africa

REFERENCES 1. Jiang Q, Li WQ, Aiello FB, et al. Cell biology of IL-7, a key lymphotrophin. Cytokine Growth Factor Rev. 2005;16:513-533. 2. Al-Shami A, Spolski R, Kelly J, et al. A role for thymic stromal lymphopoietin in CD4(1) T cell development. J Exp Med. 2004; 200:159-168. 3. Woo YL, Sterling J, Damay I, et al. Characterising the local immune responses in cervical intraepithelial neoplasia: a cross-sectional and longitudinal analysis. Br J Obstet Gynaecol. 2008;115:1616-1622. 4. Mackall CL, Fry TJ, Gress RE. Harnessing the biology of IL-7 for therapeutic application. Nat Rev Immunol. 2011;11:330-334.

Teledermatology as a means to improve access to inpatient dermatology care.

Many hospitals have limited inpatient dermatology consultation access. Most dermatologists are outpatient-based and may find the distance and time to complete inpatient consultations prohibitive. Teledermatology may improve access to inpatient dermatology care by reducing barriers of distance and time. We conducted a prospective two-phase pilot study at two academic hospitals comparing time needed to complete inpatient consultations after resident dermatologists initially evaluated patients, called average handling time (AHT), and time needed to respond to the primary team, called time to response (TTR), with and without teledermatology with surveys to capture changes in dermatologist opinion on teledermatology. Teledermatology was only used in the study phase, and patients were seen in-person in both study phases. Teledermatology alone sufficiently answered consultations in 10 of 25 study consultations. The mean AHT in the study phase (sAHT) was 26.9 min compared to the baseline phase (bAHT) of 43.5 min, a 16.6 min reduction (p = 0.004). The 10 study cases where teledermatology alone was sufficient had mean study TTR (sTTR) of 273.3 min compared to a baseline TTR (bTTR) of 405.7 min, a 132.4 min reduction (p = 0.032). Teledermatology reduces the time required for an attending dermatologist to respond and the time required for a primary team to receive a response for an inpatient dermatology consultation in a subset of cases. These findings suggest teledermatology can be used as a tool to improve access to inpatient dermatology care.

A systematic review of satisfaction with teledermatology.

Background The two most commonly used modalities of teledermatology (TD) are store-and-forward (SF) and live–interactive (LI) TD. Existing studies have not compared these tools with respect to patient and provider satisfaction. Objective To systematically review all published studies of patient and provider satisfaction with SF and LI TD. Methods PubMed, EMBASE, and Cochrane databases were systematically searched for studies on provider or patient satisfaction with SF or LI TD between January 2000 and June 2016. Results Forty eligible studies were identified: 32 with SF TD, 10 with LI TD, and 2 evaluating both. With SF TD, 96% of studies assessing patient satisfaction and 82% of studies assessing provider satisfaction demonstrated satisfaction (n = 24 and 17, respectively). With LI TD, 89% of studies assessing patient satisfaction and all studies assessing provider satisfaction revealed satisfaction (n = 9 and 6, respectively). Conclusion Patients and providers are satisfied with both SF and LI TD. Studies assessing satisfaction with LI have not been conducted in recent years, and have only been conducted in limited geographic patient populations. Further research assessing satisfaction with TD will help address any dissatisfaction with its uses and allow for increased support and funding of future programmes.

The role of physicians in asylum evaluation: documenting torture and trauma

The Role of Physicians in Asylum Evaluation: Documenting Torture and Trauma To the Editor The last several years have seen record-breaking numbers of displaced persons. An average of 42 500 people each day were forced from their homes as a result of conflict and persecution in 2014, a number 4 times higher than in 2010. Notable driving forces include Syria’s civil war, the Taliban in Afghanistan, and forced labor in Eritrea.1 The United Nations’ Convention Against Torture2 obligates nations to not expel individuals to a country where there is significant reason to believe those persons would be tortured or persecuted. The United States grants asylum to individuals that prove a wellfounded fear of persecution in court.3 Physicians are uniquely poised to help victims of torture and trauma secure asylum status. Forensic medical evaluations are used in appropriate cases to corroborate a history of trauma. Asylum seekers who receive medical evaluation in concert with legal services have success rates of 79% to 89% compared with the national average of 37.5%, suggesting that medical evaluations have considerable effect on the application process.3-5 In some cases, a forensic medical evaluation may mean the difference between an individual securing legal status and being forcibly returned to a country in which they face persecution and torture. When evaluating asylum seekers, physicians should directly and empathetically elicit a detailed history of any trauma and ask about the origin of all examination findings.4 Examples of relevant findings include lesions consistent with whipping and brachial plexus palsies caused by suspension, as well as evidence of bone fractures. In one cohort of asylum seekers, 69% had scars on their head and neck, 10% had scars on their genitals, 7% had fractured bones, and 6% had burn marks.5 Official asylum evaluations involve a history, physical examination, and review of records. In contrast to a typical clinical encounter, treatment and counseling are not provided. Physicians document any findings in a medical affidavit in the form of detailed descriptions, photographs, and/or drawings. The affidavit is subsequently submitted as corroborating evidence in court. On occasion, the physician may also testify as an expert witness. Physicians can be formally trained in performing forensic evaluations in short courses and provide this service on a volunteer, part-time basis. Given that the United States receives the third highest number of asylum applications per year,1 physicians should consider this unique opportunity to defend human rights. Furthermore, we encourage all physicians to appreciate the far-reaching effects of these traumas on all victims of forced migration.

“Pretend you didn't hear that”–managing ethical dilemmas from the bottom of a medical hierarchy

Joe Hopeful, a third-year medical student, is on his dermatology rotation. He is planning to apply in the field, and he hopes to receive a letter of recommendation from a well-known surgical attending, Dr Malaprop. A visiting female postgraduate year-3 dermatology resident interviews for a Mohs micrographic surgery fellowship position during Joe’s rotation. One afternoon, Joe overhears the current fellow asking the attending what she thinks of the applicant. Dr Malaprop responds by saying ‘‘the applicant has an impressive resume; however, she recently had a baby, and I have hesitations over whether she can fully commit to the fellowship. A couple years ago, I made a mistake by taking on a fellow who was a new mother. I can’t afford to do that again.’’ Noticing Joe in the corner, Dr Malaprop turns to him and says, ‘‘Pretend you didn’t hear that.’’

Should dermatology residents accept educational support sponsored or funded by pharmaceutical companies

As a first-year dermatology resident, Dr Jones is both impressed and intimidated by the fund of knowledge of his senior residents. They tell him that the best studying resource is a free review guide with an accompanying Web site and board and in-training examination practice questions, and they offer him a copy. The residents refer to this review book by the name of the pharmaceutical company that has sponsored its production and distribution. Although the company was not directly involved in writing the review, the review can only be obtained with the company’s sponsorship because it is not commercially available for sale. Even though the residency program’s hospital has set strict rules about physician-industry relationships and explicitly bans any gifts (including educational guides or textbooks) from industry, the residents have no trouble obtaining free copies. The company is happy to provide these copies, and the residency program director makes no effort to object.

Implementation of a dermatology teletriage system to improve access in an underserved clinic: A retrospective study

Sex, N (%) Male 39 (65.0) Female 21 (35.0) Age, years Mean (SD) 32.5 (11.4) Range 18-92 Referring provider, N (%) Nurse 35 (58.3) Physician 18 (30.0) Nurse practitioner 3 (5.0) Unknown 4 (6.7) Symptom duration, mean (SD), months 14.56 (33.65) Lesion location, N Face 11 Hand 9 Arm 6 Scalp 5 Chest 5 Oral mucosa 3 Groin 3 Leg 3 Foot 3 Whole body 2 Neck 2 Lower back and buttocks 2 Previous treatment attempted, N (%) Yes 19 (31.7) No 41 (68.3) Time to teledermatology response Mean (SD), hours 34.62 (73.80) Mean (SD), days 1.44 (3.07) Median, hours 6.28 Time to next dermatology clinic Mean (SD), hours 321.8 (214.37) Mean (SD), days 13.41 (8.93) Median, hours 315.93 Differential diagnosis concordance between referring provider and consulting dermatologist, N (%) Concordant 14 (23.3) Discordant 28 (46.7) Partially concordant 18 (30.0) Treatment plan concordance between referring provider and consulting dermatologist, N (%) Concordant 3 (5.0) Discordant 47 (78.3) Partially concordant 10 (16.7) Outcome of teledermatology consultations, N (%) Triaged completely 42 (70.0) Deferred completely to in-person evaluation 15 (25.0)

Parental leave in dermatology residency: ethical considerations.

Dr Smith is a second-year dermatology resident who just found out she is pregnant. She approaches her residency program director, Dr Barnes, for advice on taking time off for maternity leave. Dr Smith wants to spend time at home with her new infant, but she is concerned about the impact on her career, specifically being able to graduate and take the boards on schedule. She has already taken 2 weeks of vacation this year. The American Board of Dermatology (ABD) rules state that she cannot takemore than 6 weeks of leave total in any year without potentially delaying her graduation from residency. Additional time off must be made up before September 1 of her graduation year, or she may need to wait another year to take her board examination. Dr Barnes supports the resident’s choice to start a family and has a duty to protect the interests of each of her trainees. However, she has potentially conflicting duties to simultaneously protect the collective interests of her residents and the institution’s graduate medical education department to safeguard the integrity of the program in meeting accreditation standards, and a responsibility to her department to ensure that the program runs and that residents are evaluated and meet the board’s requirements to be eligible to take its certification examination. How should Dr Barnes proceed in advising Dr Smith regarding the length of her maternity leave?