PracticalDermatology

Given rising patient demand for cosmetic treatments, dermatology residents must achieve proficiency in an array of cosmetic procedures to optimize outcomes and patient safety.¹ Recent studies surveying resident attitudes and perceptions of cosmetic training in dermatology overwhelmingly echo a training gap between expected knowledge, skill, and practice of cosmetic procedures versus their actual experiences in those domains during residency.^2,3 In addition, current methods of cosmetic training are variable, ranging from an apprenticeship model to formal hands-on cosmetic training; the latter of which residents consider more valuable in developing procedural competency.³ Prior studies also gathered that dermatology residents desire cosmetic resident education to be a larger and earlier component of their curriculum.^1,3 The Accreditation Council for Graduate Medical Education (ACGME) quantitatively outlines requirements for procedural experiences, such as Mohs Micrographic Surgery. However, the guidelines for mandated experiences and level of competency in cosmetic dermatology are more nebulous, contributing to a variation of experiences across different programs.¹

The objective of this survey study was to assess the quantity and methods of current cosmetic procedural training across ACGME Dermatology Residency programs and to understand resident plans for performing cosmetic procedures after graduation. This study hopes to capture the current status of cosmetic surgery training in order to inform curricular development of residency programs to best meet resident expectations and optimize proficiency.

METHODS

Participants. Institutional review board (IRB) approval was obtained for survey protocols (IRB DL05202021). In June 2021, a recruitment letter with attached IRB-approved informed consent and a link to an anonymous survey, was electronically distributed to all accredited dermatology programs in the US through program director and/or coordinators emails acquired from the ACGME website. The survey closed six weeks after initial distribution.

Survey Design and Content. An anonymous, 37-question survey was created through Qualtrics (qualtrics.com) that allowed a maximum of one response per unique participant. Survey questions addressed participant demographics, program characteristics primarily related to cosmetic training, specifics on cosmetic procedures, and resident perspectives on cosmetic dermatology.

Statistical Analysis. Data was collected through Qualtrics and transferred to an encrypted Microsoft Excel spreadsheet on a secure online drive. Summaries of variables were outlined with percentages and measures of distribution, including mean and standard deviation. Statistical analysis was performed through Microsoft Excel.

RESULTS

Participant Demographics. Of 533 surveys sent, 31 responses were returned (response rate of 5.8 percent). Regarding the level of training of respondents, one (3.2 percent) was at the PGY-5 level, nine (29 percent) were at PGY-4, 13 (41.9 percent) at PGY-3, eight (25.8 percent) at PGY-2. The largest group of respondents received their training in the West (14 participants, 45 percent), with smaller subsets from other geographic regions (three [10 percent] Midwest, three [10 percent] Mid-South, five [16 percent] South, four [13 percent] Mid-East, two [6 percent] Mid-Atlantic, and 0 [0 percent] Northeast). The majority of programs represented had four to nine or 10-15 residents (14 responses [45.2 percent] or 12 [38.7 percent], respectively).

Program Characteristics. The second subset of questions focused on training offered by residency programs in cosmetic dermatology, which were answered by 29 unique respondents. The majority of residents (69 percent, N=20) first received exposure to cosmetic dermatology during PGY-2. Twenty-four participants (82.8 percent) reported their program had a dedicated resident cosmetic clinic, held most commonly once monthly. However, only 37.9 percent (N=11) of programs had a rotation dedicated to cosmetic procedures. All but one program (96.6 percent, N=28) hosted opportunities for residents to perform cosmetic procedures for friends, family, or staff, which was held either monthly (27.3 percent, N=6), quarterly (50 percent, N=11), annually (18.2 percent, N=4), or weekly (4.6 percent, N=1). All respondents (100 percent, N=29) reported that their program permitted attendance at conferences or other education opportunities focused on cosmetic dermatology. A large majority stated their program has faculty dedicated to resident training in cosmetic dermatology and didactic sessions about aesthetic procedures (89.7 percent [N=26] and 96.6 percent [N=28], respectively).

Information on Cosmetic Procedures. Respondents were also asked to report the numbers of specific cosmetic procedures that they have observed and reported thus far during their residency training (Table 1).

Resident Perspectives on Cosmetic Dermatology. Participants were surveyed on perspectives about their program’s cosmetic training, personal preparedness to perform a variety of cosmetic procedures after residency, and future plans for performing cosmetic procedures and pursuing a cosmetic fellowship. Of 29 unique responses, the majority of respondents stated that their program provides adequate cosmetic procedural training (65.5 percent) and that they will be prepared to perform a variety of cosmetic procedures post-residency (62.1 percent). While most report plans to perform cosmetic procedures after residency (75.9 percent) and an additional 13.8 percent remain undecided, only a minority plan to pursue a cosmetic fellowship (13.8 percent).

DISCUSSION

This study is the most recent survey assessing cosmetic dermatology training during residency and provides an update on the status of resident education and perspectives on this subspecialty within dermatology. With 96.6 percent of residents stating they receive didactic sessions on cosmetic procedures, we report a slight increase in the amount of instructional opportunities compared to most previous surveys, suggesting adaptation of dermatology curricula to meet growing demands for aesthetic treatments.^1,3,4 Our results are also consistent with prior reports of procedures most commonly encountered in residency, as botulinum toxin injections were observed or performed most often, followed by fillers and then lasers, with other procedures such as liposuction, tattoo removal, and sclerotherapy experienced more rarely.^1,3,5 Additionally, our study further contributes an evaluation of specific amounts of common aesthetic procedures observed or performed by residents. Our study highlights some deficits in resident training. For example, although the majority of residents have 10 observed botulinum toxin injections, a larger number have not encountered the minimum of 15 laser procedures, which can be fulfilled by any combination of ablative, non-ablative, or vascular lasers.⁶

Current ACGME cosmetic procedural requirements state residents have achieved proficiency for graduation if they observe and/or perform at least 15 laser procedures (any combination of ablative, non-ablative and vascular), 10 Botox procedures and 5 filler procedures. However, the threshold for achieving proficiency in cosmetic procedures is comparatively lower to the level of proficiency that is required for surgical skills/procedures (50 benign or malignant excisions performed by resident). In addition, current ACGME requirements do not require exposure to other popular cosmetic procedures such as chemical peels, other laser/light-based procedures such as intense pulsed light and laser hair removal, or platelet-rich plasma.

Although prior reports suggest some hesitancy in program directors and other leaders about the necessity and comparative value of cosmetic training,^5,7 this report emphasizes the importance of training, as a large majority of residents reported plans to perform cosmetic dermatology procedures post-residency and there remain gaps in comfort with these procedures. While approximately two-thirds of residents felt their program provided adequate training in performing cosmetic procedures, an even higher number (76 percent) stated they plan to perform these procedures after residency, with an additional 14 percent remaining undecided. While there are differing opinions about how much cosmetic surgery should be taught in residency,⁵ the majority of residents plan to incorporate it into their practice and a small subset do not feel they received adequate training.

There are several limitations with this study. First, response rate and amount of respondents were relatively low, although they still provide insight to inform this descriptive study. Additionally, our results are based on self-report, potentially contributing to inaccuracy. With the low response rate, the results may also be skewed as those respondents who chose to answer may have more interest or stronger opinions on the topic. Lastly, the largest group of respondents received their training on the West Coast, with less representation from other geographic areas and poor representation from Northeast and Atlantic regions. If geographic differences in cosmetic dermatology training exist, they were likely not captured.

CONCLUSION

In conclusion, although the response rate of our study was relatively low, it corroborates findings from prior studies and highlights a continued need to 1.) provide specific guidelines for implementing a more standardized cosmetic dermatology residency curriculum and 2.) adapt a curriculum that offers a wider array and quantity of cosmetic exposures to meet the rising patient demands.

Based on a presentation given at Cosmetic Surgery Froum 2021 in Nashville (CosmeticSurgery Forum.com). Dr. Desai was selected as one of the Top 10 Resident presenters from the 2021 meeting.

1. Kirby JS, Adgerson CN, Anderson BE. A survey of dermatology resident education in cosmetic procedures. Journal of the American Academy of Dermatology. 2013;68(2):e23-e28.

2. Waldman A, Sobanko JF, Alam M. Practice and Educational Gaps in Cosmetic Dermatologic Surgery. Dermatol Clin. 2016;34(3):341-346.

3. Group A, Philips R, Kelly E. Cosmetic dermatology training in residency: results of a survey from the residents’ perspective. Dermatol Surg. 2012;38(12):1975-1980.

4. Champlain A, Reserva J, Webb K, et al. Cosmetic Dermatology Training During Residency: Outcomes of a Resident-Reported Survey. Dermatol Surg. 2018;44(9):1216-1219.

5. Bauer B, Williams E, Stratman EJ. Cosmetic dermatologic surgical training in US dermatology residency programs: identifying and overcoming barriers. JAMA Dermatol. 2014;150(2):125-129.

6. Accreditation Council for Graduate Medical Education: Dermatology. Accessed August 12, 2021. https://acgme.org/Specialties/Documents-and-Resources/pfcatid/3/Dermatology/

7. Schleichert R, Hostetler SG, Zirwas M. The perceived influence of cosmetic dermatology on dermatology resident education. J Am Acad Dermatol. 2010;63(2):352-353.

8. Worley B, Verma L, Macdonald J. Aesthetic Dermatologic Surgery Training in Canadian Residency Programs. J Cutan Med Surg. 2019;23(2):164-173.

9. Lee EH, Nehal KS, Dusza SW, Hale EK, Levine VJ. Procedural dermatology training during dermatology residency: a survey of third-year dermatology residents. J Am Acad Dermatol. 2011;64(3):475-483, 483.e1-5.