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Dermatology

Dermatology Rotation Educational Goals & Objectives

The Dermatology rotation will provide the resident with an opportunity to recognize and treat
acute and chronic skin conditions. The resident will learn to identify and characterize physical
findings typical of common skin disorders as well as findings that precede or reflect systemic
illness, such as metabolic, neoplastic, and connective tissue disorders. The focus will be on
treatment of dermatologic complaints primary care physicians commonly see, such as acne, hair
loss or excessive growth, nail issues, pruritis, and skin lesions. Residents will become skilled in
the skin exam, develop skills in educating patients regarding sun exposure and other-skin-related
issues, and learn appropriate indications for dermatology referral.

Faculty will facilitate learning in the 6 core competencies as follows:

Patient Care and Procedural Skills

I. All residents must be able to provide compassionate, culturally-sensitive care for
patients with dermatologic complaints.

  • PGY1s should recognize the social impact that conditions affecting appearance have on patients.
  • PGY2s should be able to formulate specific questions for and arrange timely referral to dermatologists and other subspecialists as appropriate.
  • PGY3s should be able to coordinate input from multiple consultants, for example in the setting of neoplastic or rheumatologic conditions, and manage conflicting recommendations.

II. All residents will demonstrate the ability to take a focused dermatologic history and
incorporate information from the electronic medical record.

  • PGY1s should be able to elicit risk factors for skin cancer and recognize skin conditions that require emergent evaluation.
  • PGY2s will independently obtain the above information and identify barriers to patient compliance and care.
  • PGY3s should be able to independently obtain the above details for patients with complex medical histories and multiple comorbid conditions.

III. Residents should be able to perform an appropriately-targeted physical exam.

  • PGY1s should be comfortable with performing and documenting a preventive skin exam and be able to characterize age-related skin changes, normal hair growth patterns, and other benign skin conditions.
  • PGY2s should be able to describe abnormal skin, nail, and hair exam findings pertinent to the presenting complaint.
  • PGY3s should be able to independently perform a complete skin exam and understand the sensitivity and specificity of physical findings.

IV. Residents will be exposed to a number of commonly performed dermatologic
procedures. Focus during the rotation will be on learning the indications,
contraindications, complications, limitations, and interpretation of these procedures.
Residents will spend additional time in skills labs and Continuity Clinic to become
competent in their safe and effective use.

  • PGY1s: cryosurgery/application of chemical treatment for lesions such as condyloma, molluscum, and warts; dermoscopy; incision and drainage of fluctuant lesions; injection of local anesthesia and steroids; punch biopsy; skin closure techniques (Steri-strips, skin glues, suturing); skin scraping and microscopic exam; and Tzanck smear
  • PGY2s: electrodesiccation and curettage; shave biopsy
  • PGY3s: excisional biopsy

Medical Knowledge

I. Residents will hone observational skills and become fluent in pattern recognition.

II. PGY1s will become skilled in the approach to common presenting complaints,
including

  • Acne
  • Alopecia and hirsuitism
  • Aphthous ulcers
  • Bedbugs, lice, scabies and other infestations
  • Bites and stings
  • Blisters
  • Changes in freckles/moles
  • Corns/calluses
  • Cysts
  • Hives
  • Hyper- and hypopigmentation
  • Itching
  • Nail infections and deformities
  • Pressure sores and skin ulcers
  • Rash
  • Skin papules or nodules
  • Vesicular eruptions
  • Warts

PGY2s should be able to incorporate presenting information into the context of past
medical history and recognize the connection with systemic diseases, such as AIDS,
diabetes, hyperlipidemia, and SLE.

PGY3s should be able to understand statistical concepts such as pretest probability,
number needed to treat, etc. and their effect on diagnostic workup and treatment.

III. PGY2s will also develop an understanding of the pathophysiology, clinical
presentation, natural history, and therapy for the following conditions:

  • Actinic keratosis
  • Bullous pemphigoid
  • Cellulitis
  • Common skin cancers: basal and squamous cell carcinomas, Kaposi sarcoma, melanoma
  • Dermatitis
  • Drug eruptions
  • Eczema
  • Erythema multiforme
  • Erythema nodosum
  • Herpes zoster
  • Lichen planus
  • Nevi
  • Pemphigus vulgaris
  • Photosensitivity
  • Psoriasis
  • Rosacea
  • Seborrheic dermatitis
  • Toxic topical exposures
  • Urticaria

IV. PGY3s will gain a better understanding of the above conditions within the setting of
comorbidities.

V. Residents will understand the appropriate use of antibiotics, systemic steroids, and
topical steroids (classes/potency).

VI. Residents will

  • Understand indications for skin screening examinations in the general population and in the setting of systemic disease
  • Be familiar with USPTF guidelines on skin cancer
  • Be familiar with the principles and practice of wound care
  • Be familiar with indications, contraindications, and follow up for Moh’s procedure

VII. Residents will understand indications for ordering and interpretation of lab,
microbiology, and pathology results relevant to the diagnosis and treatment of the
above conditions.

Practice-Based Learning and Improvement

I. Residents should be able to access current clinical practice guidelines and apply
evidence-based strategies to patient care.

II. PGY2s should develop skills in evaluating studies in published literature, through
Journal Club and independent study.

III. All residents should learn to function as part of a team, including the primary care
physician, dermatologist, nurse, and clinic staff, to optimize patient care.

IV. PGY3s should ensure policies are in place within their practice to track and respond
appropriately to biopsy and culture results.

V. All residents should respond with positive changes to feedback from members of the
health care team.

Interpersonal and Communication Skills

I. PGY1s must demonstrate organized and articulate written (electronic) and verbal
communication skills that build rapport with patients and families, convey
information to other health care professionals, and provide timely documentation in
the chart.

II. PGY2s must also develop interpersonal skills to educate and counsel patients
regarding sunscreen use, wound healing, and skin cancer.

III. PGY3s should demonstrate leadership skills to build consensus and coordinate a
multidisciplinary approach to patient care.

Professionalism

I. All residents must demonstrate strong commitment to carrying out professional
responsibilities as reflected in their conduct, ethical behavior, attire, interactions with
colleagues and community, and devotion to patient care.

II. All residents should be able to educate patients and their families in a manner
respectful of gender, age, culture, race, religion, disabilities, national origin,
socioeconomic status, and sexual orientation on choices regarding their care.

III. PGY2s should be able to use time efficiently in the clinic to see patients and chart
information.

IV. PGY3s should be able to provide constructive criticism and feedback to more junior
members of the team.

Systems-Based Practice

I. PGY1s must have a basic understanding that their diagnostic and treatment decisions
involve cost and risk and affect quality of care.

II. PGY2s must be able to discuss alternative care strategies, taking into account the
social, economic, and psychological factors that affect patient health and use of
resources.

III. PGY2s should understand the impact of insurance status on patient access to care.

IV. PGY3s must demonstrate an awareness of and responsiveness to established quality
measures, risk management strategies, and cost of care within our system.

Teaching Methods

I. Supervised patient care in the clinic

  • Residents will initially be directly observed with patients, to facilitate the acquisition of excellent history taking and exam skills.
  • As residents become more proficient, they will interact more independently withpatients and present cases to faculty.
    • For PGY1s, initial emphasis will be on diagnosis and basic management.
    • For more senior residents, focus will be on medical decision-making, and residents will work with supervising physicians to finalize a care plan.

II. Conferences

  • Daily noon conference
  • Journal club

III. Independent study

Evaluation

I. Case and procedure logs as appropriate

II. Attending written evaluation of resident at the end of the month, based on
observations and chart review.

III. Mini-CEX bedside evaluation.

Rotation Structure

I. Residents should contact the attending physician the day prior to confirm start time
and location. Residents should notify the attending physician promptly if they cannot
be in clinic at their assigned time.

II. Residents should be in clinic during their scheduled times.

  • Residents will be involved in discussion of patient presentation, generation of a differential diagnosis, development of a treatment plan, and plan for patient follow up.
  • Case-based learning is most effective. Nightly reading/study should be based on patients seen during the day.
  • When seeing outpatient consults referred from another provider, the resident should understand the question asked and provide a concise answer.

III. Residents may be asked to do focused literature searches or presentations during the
course of the rotation.

IV. Call and weekend responsibilities TBD by the attending physician.

  • Hours worked must be consistent with ACGME requirements and are subject to approval by the Program Director.

V. Residents have noon conferences and should be excused in a timely fashion to attend.