Article

Case Example

A 37-year-old female never smoker presents to your clinic with progressive dyspnea over the past 15 years. She reports dyspnea on exertion, wheezing, chronic nasal congestion, and difficulty sleeping that started a year after she returned from military deployment to Iraq. She has been unable to exercise, even at low intensity, for the past 5 years, despite being previously active. She has experienced some symptom improvement by taking an albuterol inhaler as needed, loratadine (10 mg), and fluticasone nasal spray (50 mcg). She occasionally uses famotidine for reflux (40 mg). She deployed to Southwest Asia for 12 months (2002-2003) and was primarily stationed in Qayyarah West, an Air Force base in the Mosul district in northern Iraq. She reports exposure during deployment to the fire in the Al-Mishraq sulfur mine, located approximately 25 km north of Qayyarah West, as well as dust storms and burn pits. She currently works as a medical assistant. Her examination is remarkable for normal bronchovesicular breath sounds without any wheezing or crackles on pulmonary evaluation. Her body mass index is 31. You obtain a chest radiograph and spirometry, which are both normal.

The veteran reports feeling frustrated as she has had multiple specialty evaluations in community clinics without receiving a diagnosis, despite worsening symptoms. She reports that she added her information to the Airborne Hazards and Open Burn Pit Registry (AHOBPR). She recently received a letter from the US Department of Veterans Affairs (VA) Post-Deployment Cardiopulmonary Evaluation Network (PDCEN) and is asking you whether she should participate in the PDCEN specialty evaluation. You are not familiar with the military experiences she has described or the programs she asks you about; however, you would like to know more to best care for your patient.

Background

The year 2021 marked the 20th anniversary of the September 11 attacks and the launch of the Global War on Terrorism. Almost 3 million US military personnel have been deployed in support of these operations along with about 300,000 US civilian contractors and thousands of troops from more than 40 nations.^1-3

Deployment after 2001 to Afghanistan and the Southwest Asia theater of operations, which includes but is not limited to Iraq, Kuwait, and Saudi Arabia, has been associated with increased prevalence of dyspnea and cough as well as diagnoses of asthma, chronic obstructive pulmonary disease (COPD), and other chronic respiratory diseases.^4-9 Expert committees convened by the National Academies of Sciences, Engineering, and Medicine concluded that deployment to the Southwest Asia region and Afghanistan was associated with respiratory symptoms of cough, wheeze, and shortness of breath and might be associated with long-term health effects, particularly in vulnerable (eg, individuals with asthma) or highly exposed populations (eg, those assigned to work at burn pits).^10,11 Several reports have found constrictive bronchiolitis, emphysema, granulomatous inflammation, and pigment deposition on lung biopsy in deployed persons with unexplained dyspnea and subtle, or normal, clinical findings.^12-14

Respiratory hazards associated with deployment to Southwest Asia and Afghanistan are unique and varied. These exposures include blast injuries and a variety of particulate matter sources, such as burn pit combustion byproducts, aeroallergens, and dust storms.^7,8,15,16 One air sampling study conducted at 15 deployment sites in Southwest Asia and Afghanistan found mean fine particulate matter (PM_2.5) levels were as much as 10 times greater than sampling sites in both rural and urban cities in the United States; all sites sampled exceeded military exposure guidelines (65 µg/m³ for 1 year).^17,18 Long-term exposure to PM_2.5 has been associated with the development of chronic respiratory and cardiovascular disease; therefore, there has been considerable attention to the respiratory (and nonrespiratory) health of deployed military personnel.¹⁹

Concerns regarding the association between deployment and lung disease led to the creation of the national VA Airborne Hazards and Open Burn Pit Registry (AHOBPR) in 2014 and consists of (1) an online questionnaire to document deployment and medical history, exposure concerns, and symptoms; and (2) an optional in-person or virtual clinical health evaluation at the individual’s local VA medical center or military treatment facility (MTF). As of March 2022, more than 300,000 individuals have completed the online questionnaire of which about 30% declined the optional clinical health evaluation.

The clinical evaluation available to AHOBPR participants has not yet been described in the literature. Therefore, our objectives are to examine AHOBPR clinical evaluation data and review its application throughout the VA. In addition, we will also describe a parallel effort by the VA PDCEN, which is to provide comprehensive multiday clinical evaluations for unique AHOBPR participants with unexplained dyspnea and self-reported respiratory disease. A secondary aim of this publication is to disseminate information to health care professionals (HCPs) within and outside of the VA to aid in the referral and evaluation of previously deployed veterans who experience unexplained dyspnea.

AHOBPR Overview

The AHOBPR is an online questionnaire and optional in-person health evaluation that includes 7 major categories targeting deployment history, symptoms, medical history, health concerns, residential history, nonmilitary occupational history, nonmilitary environmental exposures, and health care utilization. The VA Defense Information Repository is used to obtain service dates for the service member/veteran, conflict involvement, and primary location during deployment. The questionnaire portion of the AHOBPR is administered online. It currently is open to all veterans who served in the Southwest Asia theater of operations (including Iraq, Kuwait, and Egypt) any time after August 2, 1990, or Afghanistan, Djibouti, Syria, or Uzbekistan after September 11, 2001. Veterans are eligible for completing the AHOBPR and optional health evaluation at no cost to the veteran regardless of VA benefits or whether they are currently enrolled in VA health care. Though the focus of the present manuscript is to profile a VA program, it is important to note that the US Department of Defense (DoD) is an active partner with the VA in the promotion of the AHOBPR to service members and similarly provides health evaluations for active-duty service members (including activating Reserve and Guard) through their local MTF.

We reviewed and analyzed AHOBPR operations and VA data from 2014 to 2020. Our analyses were limited to veterans seeking evaluation as well as their corresponding symptoms and HCP’s clinical impression from the electronic health record. As of September 20, 2021, 267,125 individuals completed the AHOBPR. The mean age was 43 years (range, 19-84), and the majority were male (86%) and served in the Army (58%). Open-air burn pits (91%), engine maintenance (38.8%), and convoy operations (71.7%) were the most common deployment-related exposures.

The optional in-person AHOBPR health evaluation may be requested by the veteran after completing the online questionnaire and is performed at the veteran’s local VA facility. The evaluation is most often completed by an environmental health clinician or primary care practitioner (PCP). A variety of resources are available to providers for training on this topic, including fact sheets, webinars, monthly calls, conferences, and accredited e-learning.²⁰ As part of the clinical evaluation, the veteran’s chief concerns are assessed and evaluated. At the time of our analysis, 24,578 clinical examinations were performed across 126 VA medical facilities, with considerable geographic variation. Veterans receiving evaluations were predominantly male (89%) with a median age of 46.0 years (IQR, 15). Veterans’ major respiratory concerns included dyspnea (45.1%), decreased exercise ability (34.8%), and cough > 3 weeks (30.3%) (Table). After clinical evaluation by a VA or MTF HCP, 47.8% were found to have a respiratory diagnosis, including asthma (30.1%), COPD (12.8%), and bronchitis (11.9%).

Post-Deployment Cardiopulmonary Evaluation Network Clinical Evaluation

In May 2019, the VA established the Airborne Hazards and Burn Pits Center of Excellence (AHBPCE). One of the AHBPCE’s objectives is to deliver specialized care and consultation for veterans with concerns about their postdeployment health, including, but not limited to, unexplained dyspnea. To meet this objective, the AHBPCE developed the PDCEN, a national network consisting of specialty HCPs from 5 VA medical centers—located in San Francisco, California; Denver, Colorado; Baltimore, Maryland; Ann Arbor, Michigan; and East Orange, New Jersey. Collectively, the PDCEN has developed a standardized approach for the comprehensive clinical evaluation of unexplained dyspnea that is implemented uniformly across sites. Staff at the PDCEN screen the AHOBPR to identify veterans with features of respiratory disease and invite them to participate in an in-person evaluation at the nearest PDCEN site. Given the specialty expertise (detailed below) within the Network, the PDCEN focuses on complex cases that are resource intensive. To address complex cases of unexplained dyspnea, the PDCEN has developed a core clinical evaluation approach (Figure).

The first step in a veteran’s PDCEN evaluation entails a set of detailed questionnaires that request information about the veteran’s current respiratory, sleep, and mental health symptoms and any associated medical diagnoses. Questionnaires also identify potential exposures to military burn pits, sulfur mine and oil field fires, diesel exhaust fumes, dust storms, urban pollution, explosions/blasts, and chemical weapons. In addition, the questionnaires include deployment geographic location, which may inform future estimates of particulate matter exposure.²¹ Prior VA and non-VA evaluations and testing of their respiratory concerns are obtained for review. Exposure and health records from the DoD are also reviewed when available.

The next step in the PDCEN evaluation comprises comprehensive testing, including complete pulmonary function testing, methacholine challenge, cardiopulmonary exercise testing, forced oscillometry and exhaled nitric oxide testing, paired high-resolution inspiratory and expiratory chest computed tomography (CT) imaging, sinus CT imaging, direct flexible laryngoscopy, echocardiography, polysomnography, and laboratory blood testing. The testing process is managed by local site coordinators and varies by institution based on availability of each testing modality and subspecialist appointments.

Once testing is completed, the veteran is evaluated by a team of HCPs, including physicians from the disciplines of pulmonary medicine, environmental and occupational health, sleep medicine, otolaryngology and speech pathology, and mental health (when appropriate). After the clinical evaluation has been completed, this team of expert HCPs at each site convenes to provide a final summary review visit intended to be a comprehensive assessment of the veteran’s primary health concerns. The 3 primary objectives of this final review are to inform the veteran of (1) what respiratory and related conditions they have; (2) whether the conditions is/are deployment related; and (3) what treatments and/or follow-up care may enhance their current state of health in partnership with their local HCPs. The PDCEN does not provide ongoing management of any conditions identified during the veteran’s evaluation but communicates findings and recommendations to the veteran and their PCP for long-term care.

Discussion

The AHOBPR was established in response to mounting concerns that service members and veterans were experiencing adverse health effects that might be attributable to deployment-related exposures. Nearly half of all patients currently enrolled in the AHOBPR report dyspnea, and about one-third have decreased exercise tolerance and/or cough. Of those who completed the questionnaire and the subsequent in-person and generalized AHOBPR examination, our interim analysis showed that about half were assigned a respiratory diagnosis. Yet for many veterans, their breathing symptoms remained unexplained or did not respond to treatment.

While the AHOBPR and related examinations address the needs of many veterans, others may require more comprehensive examination. The PDCEN attends to the latter by providing more detailed and comprehensive clinical evaluations of veterans with deployment-related respiratory health concerns and seeks to learn from these evaluations by analyzing data obtained from veterans across sites. As such, the PDCEN hopes not only to improve the health of individual veterans, but also create standard practices for both VA and non-VA community evaluation of veterans exposed to respiratory hazards during deployment.

One of the major challenges in the field of postdeployment respiratory health is the lack of clear universal language or case definitions that encompass the veteran’s clinical concerns. In an influential case series published in 2011, 38 (77%) of 49 soldiers with history of airborne hazard exposure and unexplained exercise intolerance were reported to have histopathology consistent with constrictive bronchiolitis on surgical lung biopsy.¹⁴ Subsequent publications have described other histopathologic features in deployed military personnel, including granulomatous inflammation, interstitial lung disease, emphysema, and pleuritis.^12-14 Reconciling these findings from surgical lung biopsy with the clinical presentation and noninvasive studies has proved difficult. Therefore, several groups of investigators have proposed terms, including postdeployment respiratory syndrome, deployment-related distal lung disease, and Iraq/Afghanistan War lung injury to describe the increased respiratory symptoms and variety of histopathologic and imaging findings in this population.^9,12,22 At present, there remains a lack of consensus on terminology and case definitions as well as the role of military environmental exposures in exacerbating and/or causing these conditions. As HCPs, it is important to appreciate and acknowledge that the ambiguity and controversy pertaining to terminology, causation, and service connections are a common source of frustration experienced by veterans, which are increasingly reflected among reports in popular media and lay press.

A second and related challenge in the field of postdeployment respiratory health that contributes to veteran and HCP frustration is that many of the aforementioned abnormalities described on surgical lung biopsy are not readily identifiable on noninvasive tests, including traditional interpretation of pulmonary function tests or chest CT imaging.^12-14,22 Thus, underlying conditions could be overlooked and veterans’ concerns and symptoms may be dismissed or misattributed to other comorbid conditions. While surgical lung biopsies may offer diagnostic clarity in identifying lung disease, there are significant procedural risks of surgical and anesthetic complications. Furthermore, a definitive diagnosis does not necessarily guarantee a clear treatment plan. For example, there are no current therapies approved by the US Food and Drug Administration for the treatment of constrictive bronchiolitis.

Research efforts are underway, including within the PDCEN, to evaluate a more sensitive and noninvasive assessment of the small airways that may even reduce or eliminate the need for surgical lung biopsy. In contrast to traditional pulmonary function testing, which is helpful for evaluation of the larger airways, forced oscillation technique can be used noninvasively, using pressure oscillations to evaluate for diseases of the smaller airways and has been used in the veteran population and in those exposed to dust from the World Trade Center disaster.^23-25 Multiple breath washout technique provides a lung clearance index that is determined by the number of lung turnovers it takes to clear the lungs of an inert gas (eg, sulfur hexafluoride, nitrogen). Elevated lung clearance index values suggest ventilation heterogeneity and have been shown to be higher among deployed veterans with dyspnea.^26,27 Finally, advanced CT analytic techniques may help identify functional small airways disease and are higher in deployed service members with constrictive bronchiolitis on surgical lung biopsy.²⁸ These innovative noninvasive techniques are experimental but promising, especially as part of a broader evaluation of small airways disease.

AHOBPR clinical evaluations represent an initial step to better understand postdeployment health conditions available to all AHOBPR participants. The PDCEN clinical evaluation extends the AHOBPR evaluation by providing specialty care for certain veterans requiring more comprehensive evaluation while systematically collecting and analyzing clinical data to advance the field. The VA is committed to leveraging these data and all available expertise to provide a clear description of the spectrum of disease in this population and improve our ability to diagnose, follow, and treat respiratory health conditions occurring after deployment to Southwest Asia and Afghanistan.

Case Conclusion

The veteran was referred to a PDCEN site and underwent a comprehensive multidisciplinary evaluation. Pulmonary function testing showed lung volumes and vital capacity within the predicted normal range, mild air trapping, and a low diffusion capacity for carbon monoxide. Methacholine challenge testing was normal; however, forced oscillometry suggested small airways obstruction. A high-resolution CT showed air trapping without parenchymal changes. Cardiopulmonary exercise testing demonstrated a peak exercise capacity within the predicted normal range but low breathing reserve. Otolaryngology evaluation including laryngoscopy suggested chronic nonallergic rhinitis.

At the end of the veteran’s evaluation, a summary review reported nonallergic rhinitis and distal airway obstruction consistent with small airways disease. Both were reported as most likely related to deployment given her significant environmental exposures and the temporal relationship with her deployment and symptom onset as well as lack of other identifiable causes. A more precise histopathologic diagnosis could be firmly established with a surgical lung biopsy, but after shared decision making with a PDCEN HCP, the patient declined to undergo this invasive procedure. After you review the summary review and recommendations from the PDCEN group, you start the veteran on intranasal steroids and a combined inhaled corticosteroid/long-acting β agonist inhaler as well as refer the veteran to pulmonary rehabilitation. After several weeks, she reports an improvement in sleep and nasal symptoms but continues to experience residual exercise intolerance.

This case serves as an example of the significant limitations that a previously active and healthy patient can develop after deployment to Southwest Asia and Afghanistan. Encouraging this veteran to complete the AHOBPR allowed her to be considered for a PDCEN evaluation that provided the opportunity to undergo a comprehensive noninvasive evaluation of her chronic dyspnea. In doing so, she obtained 2 important diagnoses and data from her evaluation will help establish best practices for standardized evaluations of respiratory concerns following deployment. Through the AHOBPR and PDCEN, the VA seeks to better understand postdeployment health conditions, their relationship to military and environmental exposures, and how best to diagnose and treat these conditions.

Acknowledgments

This work was supported by the US Department of Veterans Affairs (VA) Airborne Hazards and Burn Pits Center of Excellence (Public Law 115-929). The authors acknowledge support and contributions from Dr. Eric Shuping and leadership at VA’s Health Outcomes Military Exposures office as well as the New Jersey War Related Illness and Injury Study Center. In addition, we thank Erin McRoberts and Rajeev Swarup for their contributions to the Post-Deployment Cardiopulmonary Evaluation Network. Post-Deployment Cardiopulmonary Evaluation Network members:

Mehrdad Arjomandi, Caroline Davis, Michelle DeLuca, Nancy Eager, Courtney A. Eberhardt, Michael J. Falvo, Timothy Foley, Fiona A.S. Graff, Deborah Heaney, Stella E. Hines, Rachel E. Howard, Nisha Jani, Sheena Kamineni, Silpa Krefft, Mary L. Langlois, Helen Lozier, Simran K. Matharu, Anisa Moore, Lydia Patrick-DeLuca, Edward Pickering, Alexander Rabin, Michelle Robertson, Samantha L. Rogers, Aaron H. Schneider, Anand Shah, Anays Sotolongo, Jennifer H. Therkorn, Rebecca I. Toczylowski, Matthew Watson, Alison D. Wilczynski, Ian W. Wilson, Romi A. Yount.

Case Example

A 37-year-old female never smoker presents to your clinic with progressive dyspnea over the past 15 years. She reports dyspnea on exertion, wheezing, chronic nasal congestion, and difficulty sleeping that started a year after she returned from military deployment to Iraq. She has been unable to exercise, even at low intensity, for the past 5 years, despite being previously active. She has experienced some symptom improvement by taking an albuterol inhaler as needed, loratadine (10 mg), and fluticasone nasal spray (50 mcg). She occasionally uses famotidine for reflux (40 mg). She deployed to Southwest Asia for 12 months (2002-2003) and was primarily stationed in Qayyarah West, an Air Force base in the Mosul district in northern Iraq. She reports exposure during deployment to the fire in the Al-Mishraq sulfur mine, located approximately 25 km north of Qayyarah West, as well as dust storms and burn pits. She currently works as a medical assistant. Her examination is remarkable for normal bronchovesicular breath sounds without any wheezing or crackles on pulmonary evaluation. Her body mass index is 31. You obtain a chest radiograph and spirometry, which are both normal.

The veteran reports feeling frustrated as she has had multiple specialty evaluations in community clinics without receiving a diagnosis, despite worsening symptoms. She reports that she added her information to the Airborne Hazards and Open Burn Pit Registry (AHOBPR). She recently received a letter from the US Department of Veterans Affairs (VA) Post-Deployment Cardiopulmonary Evaluation Network (PDCEN) and is asking you whether she should participate in the PDCEN specialty evaluation. You are not familiar with the military experiences she has described or the programs she asks you about; however, you would like to know more to best care for your patient.

Background

The year 2021 marked the 20th anniversary of the September 11 attacks and the launch of the Global War on Terrorism. Almost 3 million US military personnel have been deployed in support of these operations along with about 300,000 US civilian contractors and thousands of troops from more than 40 nations.^1-3

Deployment after 2001 to Afghanistan and the Southwest Asia theater of operations, which includes but is not limited to Iraq, Kuwait, and Saudi Arabia, has been associated with increased prevalence of dyspnea and cough as well as diagnoses of asthma, chronic obstructive pulmonary disease (COPD), and other chronic respiratory diseases.^4-9 Expert committees convened by the National Academies of Sciences, Engineering, and Medicine concluded that deployment to the Southwest Asia region and Afghanistan was associated with respiratory symptoms of cough, wheeze, and shortness of breath and might be associated with long-term health effects, particularly in vulnerable (eg, individuals with asthma) or highly exposed populations (eg, those assigned to work at burn pits).^10,11 Several reports have found constrictive bronchiolitis, emphysema, granulomatous inflammation, and pigment deposition on lung biopsy in deployed persons with unexplained dyspnea and subtle, or normal, clinical findings.^12-14

Respiratory hazards associated with deployment to Southwest Asia and Afghanistan are unique and varied. These exposures include blast injuries and a variety of particulate matter sources, such as burn pit combustion byproducts, aeroallergens, and dust storms.^7,8,15,16 One air sampling study conducted at 15 deployment sites in Southwest Asia and Afghanistan found mean fine particulate matter (PM_2.5) levels were as much as 10 times greater than sampling sites in both rural and urban cities in the United States; all sites sampled exceeded military exposure guidelines (65 µg/m³ for 1 year).^17,18 Long-term exposure to PM_2.5 has been associated with the development of chronic respiratory and cardiovascular disease; therefore, there has been considerable attention to the respiratory (and nonrespiratory) health of deployed military personnel.¹⁹

Concerns regarding the association between deployment and lung disease led to the creation of the national VA Airborne Hazards and Open Burn Pit Registry (AHOBPR) in 2014 and consists of (1) an online questionnaire to document deployment and medical history, exposure concerns, and symptoms; and (2) an optional in-person or virtual clinical health evaluation at the individual’s local VA medical center or military treatment facility (MTF). As of March 2022, more than 300,000 individuals have completed the online questionnaire of which about 30% declined the optional clinical health evaluation.

The clinical evaluation available to AHOBPR participants has not yet been described in the literature. Therefore, our objectives are to examine AHOBPR clinical evaluation data and review its application throughout the VA. In addition, we will also describe a parallel effort by the VA PDCEN, which is to provide comprehensive multiday clinical evaluations for unique AHOBPR participants with unexplained dyspnea and self-reported respiratory disease. A secondary aim of this publication is to disseminate information to health care professionals (HCPs) within and outside of the VA to aid in the referral and evaluation of previously deployed veterans who experience unexplained dyspnea.

AHOBPR Overview

The AHOBPR is an online questionnaire and optional in-person health evaluation that includes 7 major categories targeting deployment history, symptoms, medical history, health concerns, residential history, nonmilitary occupational history, nonmilitary environmental exposures, and health care utilization. The VA Defense Information Repository is used to obtain service dates for the service member/veteran, conflict involvement, and primary location during deployment. The questionnaire portion of the AHOBPR is administered online. It currently is open to all veterans who served in the Southwest Asia theater of operations (including Iraq, Kuwait, and Egypt) any time after August 2, 1990, or Afghanistan, Djibouti, Syria, or Uzbekistan after September 11, 2001. Veterans are eligible for completing the AHOBPR and optional health evaluation at no cost to the veteran regardless of VA benefits or whether they are currently enrolled in VA health care. Though the focus of the present manuscript is to profile a VA program, it is important to note that the US Department of Defense (DoD) is an active partner with the VA in the promotion of the AHOBPR to service members and similarly provides health evaluations for active-duty service members (including activating Reserve and Guard) through their local MTF.

We reviewed and analyzed AHOBPR operations and VA data from 2014 to 2020. Our analyses were limited to veterans seeking evaluation as well as their corresponding symptoms and HCP’s clinical impression from the electronic health record. As of September 20, 2021, 267,125 individuals completed the AHOBPR. The mean age was 43 years (range, 19-84), and the majority were male (86%) and served in the Army (58%). Open-air burn pits (91%), engine maintenance (38.8%), and convoy operations (71.7%) were the most common deployment-related exposures.

The optional in-person AHOBPR health evaluation may be requested by the veteran after completing the online questionnaire and is performed at the veteran’s local VA facility. The evaluation is most often completed by an environmental health clinician or primary care practitioner (PCP). A variety of resources are available to providers for training on this topic, including fact sheets, webinars, monthly calls, conferences, and accredited e-learning.²⁰ As part of the clinical evaluation, the veteran’s chief concerns are assessed and evaluated. At the time of our analysis, 24,578 clinical examinations were performed across 126 VA medical facilities, with considerable geographic variation. Veterans receiving evaluations were predominantly male (89%) with a median age of 46.0 years (IQR, 15). Veterans’ major respiratory concerns included dyspnea (45.1%), decreased exercise ability (34.8%), and cough > 3 weeks (30.3%) (Table). After clinical evaluation by a VA or MTF HCP, 47.8% were found to have a respiratory diagnosis, including asthma (30.1%), COPD (12.8%), and bronchitis (11.9%).

Post-Deployment Cardiopulmonary Evaluation Network Clinical Evaluation

In May 2019, the VA established the Airborne Hazards and Burn Pits Center of Excellence (AHBPCE). One of the AHBPCE’s objectives is to deliver specialized care and consultation for veterans with concerns about their postdeployment health, including, but not limited to, unexplained dyspnea. To meet this objective, the AHBPCE developed the PDCEN, a national network consisting of specialty HCPs from 5 VA medical centers—located in San Francisco, California; Denver, Colorado; Baltimore, Maryland; Ann Arbor, Michigan; and East Orange, New Jersey. Collectively, the PDCEN has developed a standardized approach for the comprehensive clinical evaluation of unexplained dyspnea that is implemented uniformly across sites. Staff at the PDCEN screen the AHOBPR to identify veterans with features of respiratory disease and invite them to participate in an in-person evaluation at the nearest PDCEN site. Given the specialty expertise (detailed below) within the Network, the PDCEN focuses on complex cases that are resource intensive. To address complex cases of unexplained dyspnea, the PDCEN has developed a core clinical evaluation approach (Figure).

The first step in a veteran’s PDCEN evaluation entails a set of detailed questionnaires that request information about the veteran’s current respiratory, sleep, and mental health symptoms and any associated medical diagnoses. Questionnaires also identify potential exposures to military burn pits, sulfur mine and oil field fires, diesel exhaust fumes, dust storms, urban pollution, explosions/blasts, and chemical weapons. In addition, the questionnaires include deployment geographic location, which may inform future estimates of particulate matter exposure.²¹ Prior VA and non-VA evaluations and testing of their respiratory concerns are obtained for review. Exposure and health records from the DoD are also reviewed when available.

The next step in the PDCEN evaluation comprises comprehensive testing, including complete pulmonary function testing, methacholine challenge, cardiopulmonary exercise testing, forced oscillometry and exhaled nitric oxide testing, paired high-resolution inspiratory and expiratory chest computed tomography (CT) imaging, sinus CT imaging, direct flexible laryngoscopy, echocardiography, polysomnography, and laboratory blood testing. The testing process is managed by local site coordinators and varies by institution based on availability of each testing modality and subspecialist appointments.

Once testing is completed, the veteran is evaluated by a team of HCPs, including physicians from the disciplines of pulmonary medicine, environmental and occupational health, sleep medicine, otolaryngology and speech pathology, and mental health (when appropriate). After the clinical evaluation has been completed, this team of expert HCPs at each site convenes to provide a final summary review visit intended to be a comprehensive assessment of the veteran’s primary health concerns. The 3 primary objectives of this final review are to inform the veteran of (1) what respiratory and related conditions they have; (2) whether the conditions is/are deployment related; and (3) what treatments and/or follow-up care may enhance their current state of health in partnership with their local HCPs. The PDCEN does not provide ongoing management of any conditions identified during the veteran’s evaluation but communicates findings and recommendations to the veteran and their PCP for long-term care.

Discussion

The AHOBPR was established in response to mounting concerns that service members and veterans were experiencing adverse health effects that might be attributable to deployment-related exposures. Nearly half of all patients currently enrolled in the AHOBPR report dyspnea, and about one-third have decreased exercise tolerance and/or cough. Of those who completed the questionnaire and the subsequent in-person and generalized AHOBPR examination, our interim analysis showed that about half were assigned a respiratory diagnosis. Yet for many veterans, their breathing symptoms remained unexplained or did not respond to treatment.

While the AHOBPR and related examinations address the needs of many veterans, others may require more comprehensive examination. The PDCEN attends to the latter by providing more detailed and comprehensive clinical evaluations of veterans with deployment-related respiratory health concerns and seeks to learn from these evaluations by analyzing data obtained from veterans across sites. As such, the PDCEN hopes not only to improve the health of individual veterans, but also create standard practices for both VA and non-VA community evaluation of veterans exposed to respiratory hazards during deployment.

One of the major challenges in the field of postdeployment respiratory health is the lack of clear universal language or case definitions that encompass the veteran’s clinical concerns. In an influential case series published in 2011, 38 (77%) of 49 soldiers with history of airborne hazard exposure and unexplained exercise intolerance were reported to have histopathology consistent with constrictive bronchiolitis on surgical lung biopsy.¹⁴ Subsequent publications have described other histopathologic features in deployed military personnel, including granulomatous inflammation, interstitial lung disease, emphysema, and pleuritis.^12-14 Reconciling these findings from surgical lung biopsy with the clinical presentation and noninvasive studies has proved difficult. Therefore, several groups of investigators have proposed terms, including postdeployment respiratory syndrome, deployment-related distal lung disease, and Iraq/Afghanistan War lung injury to describe the increased respiratory symptoms and variety of histopathologic and imaging findings in this population.^9,12,22 At present, there remains a lack of consensus on terminology and case definitions as well as the role of military environmental exposures in exacerbating and/or causing these conditions. As HCPs, it is important to appreciate and acknowledge that the ambiguity and controversy pertaining to terminology, causation, and service connections are a common source of frustration experienced by veterans, which are increasingly reflected among reports in popular media and lay press.

A second and related challenge in the field of postdeployment respiratory health that contributes to veteran and HCP frustration is that many of the aforementioned abnormalities described on surgical lung biopsy are not readily identifiable on noninvasive tests, including traditional interpretation of pulmonary function tests or chest CT imaging.^12-14,22 Thus, underlying conditions could be overlooked and veterans’ concerns and symptoms may be dismissed or misattributed to other comorbid conditions. While surgical lung biopsies may offer diagnostic clarity in identifying lung disease, there are significant procedural risks of surgical and anesthetic complications. Furthermore, a definitive diagnosis does not necessarily guarantee a clear treatment plan. For example, there are no current therapies approved by the US Food and Drug Administration for the treatment of constrictive bronchiolitis.

Research efforts are underway, including within the PDCEN, to evaluate a more sensitive and noninvasive assessment of the small airways that may even reduce or eliminate the need for surgical lung biopsy. In contrast to traditional pulmonary function testing, which is helpful for evaluation of the larger airways, forced oscillation technique can be used noninvasively, using pressure oscillations to evaluate for diseases of the smaller airways and has been used in the veteran population and in those exposed to dust from the World Trade Center disaster.^23-25 Multiple breath washout technique provides a lung clearance index that is determined by the number of lung turnovers it takes to clear the lungs of an inert gas (eg, sulfur hexafluoride, nitrogen). Elevated lung clearance index values suggest ventilation heterogeneity and have been shown to be higher among deployed veterans with dyspnea.^26,27 Finally, advanced CT analytic techniques may help identify functional small airways disease and are higher in deployed service members with constrictive bronchiolitis on surgical lung biopsy.²⁸ These innovative noninvasive techniques are experimental but promising, especially as part of a broader evaluation of small airways disease.

AHOBPR clinical evaluations represent an initial step to better understand postdeployment health conditions available to all AHOBPR participants. The PDCEN clinical evaluation extends the AHOBPR evaluation by providing specialty care for certain veterans requiring more comprehensive evaluation while systematically collecting and analyzing clinical data to advance the field. The VA is committed to leveraging these data and all available expertise to provide a clear description of the spectrum of disease in this population and improve our ability to diagnose, follow, and treat respiratory health conditions occurring after deployment to Southwest Asia and Afghanistan.

Case Conclusion

The veteran was referred to a PDCEN site and underwent a comprehensive multidisciplinary evaluation. Pulmonary function testing showed lung volumes and vital capacity within the predicted normal range, mild air trapping, and a low diffusion capacity for carbon monoxide. Methacholine challenge testing was normal; however, forced oscillometry suggested small airways obstruction. A high-resolution CT showed air trapping without parenchymal changes. Cardiopulmonary exercise testing demonstrated a peak exercise capacity within the predicted normal range but low breathing reserve. Otolaryngology evaluation including laryngoscopy suggested chronic nonallergic rhinitis.

At the end of the veteran’s evaluation, a summary review reported nonallergic rhinitis and distal airway obstruction consistent with small airways disease. Both were reported as most likely related to deployment given her significant environmental exposures and the temporal relationship with her deployment and symptom onset as well as lack of other identifiable causes. A more precise histopathologic diagnosis could be firmly established with a surgical lung biopsy, but after shared decision making with a PDCEN HCP, the patient declined to undergo this invasive procedure. After you review the summary review and recommendations from the PDCEN group, you start the veteran on intranasal steroids and a combined inhaled corticosteroid/long-acting β agonist inhaler as well as refer the veteran to pulmonary rehabilitation. After several weeks, she reports an improvement in sleep and nasal symptoms but continues to experience residual exercise intolerance.

This case serves as an example of the significant limitations that a previously active and healthy patient can develop after deployment to Southwest Asia and Afghanistan. Encouraging this veteran to complete the AHOBPR allowed her to be considered for a PDCEN evaluation that provided the opportunity to undergo a comprehensive noninvasive evaluation of her chronic dyspnea. In doing so, she obtained 2 important diagnoses and data from her evaluation will help establish best practices for standardized evaluations of respiratory concerns following deployment. Through the AHOBPR and PDCEN, the VA seeks to better understand postdeployment health conditions, their relationship to military and environmental exposures, and how best to diagnose and treat these conditions.

Acknowledgments

This work was supported by the US Department of Veterans Affairs (VA) Airborne Hazards and Burn Pits Center of Excellence (Public Law 115-929). The authors acknowledge support and contributions from Dr. Eric Shuping and leadership at VA’s Health Outcomes Military Exposures office as well as the New Jersey War Related Illness and Injury Study Center. In addition, we thank Erin McRoberts and Rajeev Swarup for their contributions to the Post-Deployment Cardiopulmonary Evaluation Network. Post-Deployment Cardiopulmonary Evaluation Network members:

Mehrdad Arjomandi, Caroline Davis, Michelle DeLuca, Nancy Eager, Courtney A. Eberhardt, Michael J. Falvo, Timothy Foley, Fiona A.S. Graff, Deborah Heaney, Stella E. Hines, Rachel E. Howard, Nisha Jani, Sheena Kamineni, Silpa Krefft, Mary L. Langlois, Helen Lozier, Simran K. Matharu, Anisa Moore, Lydia Patrick-DeLuca, Edward Pickering, Alexander Rabin, Michelle Robertson, Samantha L. Rogers, Aaron H. Schneider, Anand Shah, Anays Sotolongo, Jennifer H. Therkorn, Rebecca I. Toczylowski, Matthew Watson, Alison D. Wilczynski, Ian W. Wilson, Romi A. Yount.

Case Example

A 37-year-old female never smoker presents to your clinic with progressive dyspnea over the past 15 years. She reports dyspnea on exertion, wheezing, chronic nasal congestion, and difficulty sleeping that started a year after she returned from military deployment to Iraq. She has been unable to exercise, even at low intensity, for the past 5 years, despite being previously active. She has experienced some symptom improvement by taking an albuterol inhaler as needed, loratadine (10 mg), and fluticasone nasal spray (50 mcg). She occasionally uses famotidine for reflux (40 mg). She deployed to Southwest Asia for 12 months (2002-2003) and was primarily stationed in Qayyarah West, an Air Force base in the Mosul district in northern Iraq. She reports exposure during deployment to the fire in the Al-Mishraq sulfur mine, located approximately 25 km north of Qayyarah West, as well as dust storms and burn pits. She currently works as a medical assistant. Her examination is remarkable for normal bronchovesicular breath sounds without any wheezing or crackles on pulmonary evaluation. Her body mass index is 31. You obtain a chest radiograph and spirometry, which are both normal.

The veteran reports feeling frustrated as she has had multiple specialty evaluations in community clinics without receiving a diagnosis, despite worsening symptoms. She reports that she added her information to the Airborne Hazards and Open Burn Pit Registry (AHOBPR). She recently received a letter from the US Department of Veterans Affairs (VA) Post-Deployment Cardiopulmonary Evaluation Network (PDCEN) and is asking you whether she should participate in the PDCEN specialty evaluation. You are not familiar with the military experiences she has described or the programs she asks you about; however, you would like to know more to best care for your patient.

Background

The year 2021 marked the 20th anniversary of the September 11 attacks and the launch of the Global War on Terrorism. Almost 3 million US military personnel have been deployed in support of these operations along with about 300,000 US civilian contractors and thousands of troops from more than 40 nations.^1-3

Deployment after 2001 to Afghanistan and the Southwest Asia theater of operations, which includes but is not limited to Iraq, Kuwait, and Saudi Arabia, has been associated with increased prevalence of dyspnea and cough as well as diagnoses of asthma, chronic obstructive pulmonary disease (COPD), and other chronic respiratory diseases.^4-9 Expert committees convened by the National Academies of Sciences, Engineering, and Medicine concluded that deployment to the Southwest Asia region and Afghanistan was associated with respiratory symptoms of cough, wheeze, and shortness of breath and might be associated with long-term health effects, particularly in vulnerable (eg, individuals with asthma) or highly exposed populations (eg, those assigned to work at burn pits).^10,11 Several reports have found constrictive bronchiolitis, emphysema, granulomatous inflammation, and pigment deposition on lung biopsy in deployed persons with unexplained dyspnea and subtle, or normal, clinical findings.^12-14

Respiratory hazards associated with deployment to Southwest Asia and Afghanistan are unique and varied. These exposures include blast injuries and a variety of particulate matter sources, such as burn pit combustion byproducts, aeroallergens, and dust storms.^7,8,15,16 One air sampling study conducted at 15 deployment sites in Southwest Asia and Afghanistan found mean fine particulate matter (PM_2.5) levels were as much as 10 times greater than sampling sites in both rural and urban cities in the United States; all sites sampled exceeded military exposure guidelines (65 µg/m³ for 1 year).^17,18 Long-term exposure to PM_2.5 has been associated with the development of chronic respiratory and cardiovascular disease; therefore, there has been considerable attention to the respiratory (and nonrespiratory) health of deployed military personnel.¹⁹

Concerns regarding the association between deployment and lung disease led to the creation of the national VA Airborne Hazards and Open Burn Pit Registry (AHOBPR) in 2014 and consists of (1) an online questionnaire to document deployment and medical history, exposure concerns, and symptoms; and (2) an optional in-person or virtual clinical health evaluation at the individual’s local VA medical center or military treatment facility (MTF). As of March 2022, more than 300,000 individuals have completed the online questionnaire of which about 30% declined the optional clinical health evaluation.

The clinical evaluation available to AHOBPR participants has not yet been described in the literature. Therefore, our objectives are to examine AHOBPR clinical evaluation data and review its application throughout the VA. In addition, we will also describe a parallel effort by the VA PDCEN, which is to provide comprehensive multiday clinical evaluations for unique AHOBPR participants with unexplained dyspnea and self-reported respiratory disease. A secondary aim of this publication is to disseminate information to health care professionals (HCPs) within and outside of the VA to aid in the referral and evaluation of previously deployed veterans who experience unexplained dyspnea.

AHOBPR Overview

The AHOBPR is an online questionnaire and optional in-person health evaluation that includes 7 major categories targeting deployment history, symptoms, medical history, health concerns, residential history, nonmilitary occupational history, nonmilitary environmental exposures, and health care utilization. The VA Defense Information Repository is used to obtain service dates for the service member/veteran, conflict involvement, and primary location during deployment. The questionnaire portion of the AHOBPR is administered online. It currently is open to all veterans who served in the Southwest Asia theater of operations (including Iraq, Kuwait, and Egypt) any time after August 2, 1990, or Afghanistan, Djibouti, Syria, or Uzbekistan after September 11, 2001. Veterans are eligible for completing the AHOBPR and optional health evaluation at no cost to the veteran regardless of VA benefits or whether they are currently enrolled in VA health care. Though the focus of the present manuscript is to profile a VA program, it is important to note that the US Department of Defense (DoD) is an active partner with the VA in the promotion of the AHOBPR to service members and similarly provides health evaluations for active-duty service members (including activating Reserve and Guard) through their local MTF.

We reviewed and analyzed AHOBPR operations and VA data from 2014 to 2020. Our analyses were limited to veterans seeking evaluation as well as their corresponding symptoms and HCP’s clinical impression from the electronic health record. As of September 20, 2021, 267,125 individuals completed the AHOBPR. The mean age was 43 years (range, 19-84), and the majority were male (86%) and served in the Army (58%). Open-air burn pits (91%), engine maintenance (38.8%), and convoy operations (71.7%) were the most common deployment-related exposures.

The optional in-person AHOBPR health evaluation may be requested by the veteran after completing the online questionnaire and is performed at the veteran’s local VA facility. The evaluation is most often completed by an environmental health clinician or primary care practitioner (PCP). A variety of resources are available to providers for training on this topic, including fact sheets, webinars, monthly calls, conferences, and accredited e-learning.²⁰ As part of the clinical evaluation, the veteran’s chief concerns are assessed and evaluated. At the time of our analysis, 24,578 clinical examinations were performed across 126 VA medical facilities, with considerable geographic variation. Veterans receiving evaluations were predominantly male (89%) with a median age of 46.0 years (IQR, 15). Veterans’ major respiratory concerns included dyspnea (45.1%), decreased exercise ability (34.8%), and cough > 3 weeks (30.3%) (Table). After clinical evaluation by a VA or MTF HCP, 47.8% were found to have a respiratory diagnosis, including asthma (30.1%), COPD (12.8%), and bronchitis (11.9%).

Post-Deployment Cardiopulmonary Evaluation Network Clinical Evaluation

In May 2019, the VA established the Airborne Hazards and Burn Pits Center of Excellence (AHBPCE). One of the AHBPCE’s objectives is to deliver specialized care and consultation for veterans with concerns about their postdeployment health, including, but not limited to, unexplained dyspnea. To meet this objective, the AHBPCE developed the PDCEN, a national network consisting of specialty HCPs from 5 VA medical centers—located in San Francisco, California; Denver, Colorado; Baltimore, Maryland; Ann Arbor, Michigan; and East Orange, New Jersey. Collectively, the PDCEN has developed a standardized approach for the comprehensive clinical evaluation of unexplained dyspnea that is implemented uniformly across sites. Staff at the PDCEN screen the AHOBPR to identify veterans with features of respiratory disease and invite them to participate in an in-person evaluation at the nearest PDCEN site. Given the specialty expertise (detailed below) within the Network, the PDCEN focuses on complex cases that are resource intensive. To address complex cases of unexplained dyspnea, the PDCEN has developed a core clinical evaluation approach (Figure).

The first step in a veteran’s PDCEN evaluation entails a set of detailed questionnaires that request information about the veteran’s current respiratory, sleep, and mental health symptoms and any associated medical diagnoses. Questionnaires also identify potential exposures to military burn pits, sulfur mine and oil field fires, diesel exhaust fumes, dust storms, urban pollution, explosions/blasts, and chemical weapons. In addition, the questionnaires include deployment geographic location, which may inform future estimates of particulate matter exposure.²¹ Prior VA and non-VA evaluations and testing of their respiratory concerns are obtained for review. Exposure and health records from the DoD are also reviewed when available.

The next step in the PDCEN evaluation comprises comprehensive testing, including complete pulmonary function testing, methacholine challenge, cardiopulmonary exercise testing, forced oscillometry and exhaled nitric oxide testing, paired high-resolution inspiratory and expiratory chest computed tomography (CT) imaging, sinus CT imaging, direct flexible laryngoscopy, echocardiography, polysomnography, and laboratory blood testing. The testing process is managed by local site coordinators and varies by institution based on availability of each testing modality and subspecialist appointments.

Once testing is completed, the veteran is evaluated by a team of HCPs, including physicians from the disciplines of pulmonary medicine, environmental and occupational health, sleep medicine, otolaryngology and speech pathology, and mental health (when appropriate). After the clinical evaluation has been completed, this team of expert HCPs at each site convenes to provide a final summary review visit intended to be a comprehensive assessment of the veteran’s primary health concerns. The 3 primary objectives of this final review are to inform the veteran of (1) what respiratory and related conditions they have; (2) whether the conditions is/are deployment related; and (3) what treatments and/or follow-up care may enhance their current state of health in partnership with their local HCPs. The PDCEN does not provide ongoing management of any conditions identified during the veteran’s evaluation but communicates findings and recommendations to the veteran and their PCP for long-term care.

Discussion

The AHOBPR was established in response to mounting concerns that service members and veterans were experiencing adverse health effects that might be attributable to deployment-related exposures. Nearly half of all patients currently enrolled in the AHOBPR report dyspnea, and about one-third have decreased exercise tolerance and/or cough. Of those who completed the questionnaire and the subsequent in-person and generalized AHOBPR examination, our interim analysis showed that about half were assigned a respiratory diagnosis. Yet for many veterans, their breathing symptoms remained unexplained or did not respond to treatment.

While the AHOBPR and related examinations address the needs of many veterans, others may require more comprehensive examination. The PDCEN attends to the latter by providing more detailed and comprehensive clinical evaluations of veterans with deployment-related respiratory health concerns and seeks to learn from these evaluations by analyzing data obtained from veterans across sites. As such, the PDCEN hopes not only to improve the health of individual veterans, but also create standard practices for both VA and non-VA community evaluation of veterans exposed to respiratory hazards during deployment.

One of the major challenges in the field of postdeployment respiratory health is the lack of clear universal language or case definitions that encompass the veteran’s clinical concerns. In an influential case series published in 2011, 38 (77%) of 49 soldiers with history of airborne hazard exposure and unexplained exercise intolerance were reported to have histopathology consistent with constrictive bronchiolitis on surgical lung biopsy.¹⁴ Subsequent publications have described other histopathologic features in deployed military personnel, including granulomatous inflammation, interstitial lung disease, emphysema, and pleuritis.^12-14 Reconciling these findings from surgical lung biopsy with the clinical presentation and noninvasive studies has proved difficult. Therefore, several groups of investigators have proposed terms, including postdeployment respiratory syndrome, deployment-related distal lung disease, and Iraq/Afghanistan War lung injury to describe the increased respiratory symptoms and variety of histopathologic and imaging findings in this population.^9,12,22 At present, there remains a lack of consensus on terminology and case definitions as well as the role of military environmental exposures in exacerbating and/or causing these conditions. As HCPs, it is important to appreciate and acknowledge that the ambiguity and controversy pertaining to terminology, causation, and service connections are a common source of frustration experienced by veterans, which are increasingly reflected among reports in popular media and lay press.

A second and related challenge in the field of postdeployment respiratory health that contributes to veteran and HCP frustration is that many of the aforementioned abnormalities described on surgical lung biopsy are not readily identifiable on noninvasive tests, including traditional interpretation of pulmonary function tests or chest CT imaging.^12-14,22 Thus, underlying conditions could be overlooked and veterans’ concerns and symptoms may be dismissed or misattributed to other comorbid conditions. While surgical lung biopsies may offer diagnostic clarity in identifying lung disease, there are significant procedural risks of surgical and anesthetic complications. Furthermore, a definitive diagnosis does not necessarily guarantee a clear treatment plan. For example, there are no current therapies approved by the US Food and Drug Administration for the treatment of constrictive bronchiolitis.

Research efforts are underway, including within the PDCEN, to evaluate a more sensitive and noninvasive assessment of the small airways that may even reduce or eliminate the need for surgical lung biopsy. In contrast to traditional pulmonary function testing, which is helpful for evaluation of the larger airways, forced oscillation technique can be used noninvasively, using pressure oscillations to evaluate for diseases of the smaller airways and has been used in the veteran population and in those exposed to dust from the World Trade Center disaster.^23-25 Multiple breath washout technique provides a lung clearance index that is determined by the number of lung turnovers it takes to clear the lungs of an inert gas (eg, sulfur hexafluoride, nitrogen). Elevated lung clearance index values suggest ventilation heterogeneity and have been shown to be higher among deployed veterans with dyspnea.^26,27 Finally, advanced CT analytic techniques may help identify functional small airways disease and are higher in deployed service members with constrictive bronchiolitis on surgical lung biopsy.²⁸ These innovative noninvasive techniques are experimental but promising, especially as part of a broader evaluation of small airways disease.

AHOBPR clinical evaluations represent an initial step to better understand postdeployment health conditions available to all AHOBPR participants. The PDCEN clinical evaluation extends the AHOBPR evaluation by providing specialty care for certain veterans requiring more comprehensive evaluation while systematically collecting and analyzing clinical data to advance the field. The VA is committed to leveraging these data and all available expertise to provide a clear description of the spectrum of disease in this population and improve our ability to diagnose, follow, and treat respiratory health conditions occurring after deployment to Southwest Asia and Afghanistan.

Case Conclusion

The veteran was referred to a PDCEN site and underwent a comprehensive multidisciplinary evaluation. Pulmonary function testing showed lung volumes and vital capacity within the predicted normal range, mild air trapping, and a low diffusion capacity for carbon monoxide. Methacholine challenge testing was normal; however, forced oscillometry suggested small airways obstruction. A high-resolution CT showed air trapping without parenchymal changes. Cardiopulmonary exercise testing demonstrated a peak exercise capacity within the predicted normal range but low breathing reserve. Otolaryngology evaluation including laryngoscopy suggested chronic nonallergic rhinitis.

At the end of the veteran’s evaluation, a summary review reported nonallergic rhinitis and distal airway obstruction consistent with small airways disease. Both were reported as most likely related to deployment given her significant environmental exposures and the temporal relationship with her deployment and symptom onset as well as lack of other identifiable causes. A more precise histopathologic diagnosis could be firmly established with a surgical lung biopsy, but after shared decision making with a PDCEN HCP, the patient declined to undergo this invasive procedure. After you review the summary review and recommendations from the PDCEN group, you start the veteran on intranasal steroids and a combined inhaled corticosteroid/long-acting β agonist inhaler as well as refer the veteran to pulmonary rehabilitation. After several weeks, she reports an improvement in sleep and nasal symptoms but continues to experience residual exercise intolerance.

This case serves as an example of the significant limitations that a previously active and healthy patient can develop after deployment to Southwest Asia and Afghanistan. Encouraging this veteran to complete the AHOBPR allowed her to be considered for a PDCEN evaluation that provided the opportunity to undergo a comprehensive noninvasive evaluation of her chronic dyspnea. In doing so, she obtained 2 important diagnoses and data from her evaluation will help establish best practices for standardized evaluations of respiratory concerns following deployment. Through the AHOBPR and PDCEN, the VA seeks to better understand postdeployment health conditions, their relationship to military and environmental exposures, and how best to diagnose and treat these conditions.

Acknowledgments

This work was supported by the US Department of Veterans Affairs (VA) Airborne Hazards and Burn Pits Center of Excellence (Public Law 115-929). The authors acknowledge support and contributions from Dr. Eric Shuping and leadership at VA’s Health Outcomes Military Exposures office as well as the New Jersey War Related Illness and Injury Study Center. In addition, we thank Erin McRoberts and Rajeev Swarup for their contributions to the Post-Deployment Cardiopulmonary Evaluation Network. Post-Deployment Cardiopulmonary Evaluation Network members:

Mehrdad Arjomandi, Caroline Davis, Michelle DeLuca, Nancy Eager, Courtney A. Eberhardt, Michael J. Falvo, Timothy Foley, Fiona A.S. Graff, Deborah Heaney, Stella E. Hines, Rachel E. Howard, Nisha Jani, Sheena Kamineni, Silpa Krefft, Mary L. Langlois, Helen Lozier, Simran K. Matharu, Anisa Moore, Lydia Patrick-DeLuca, Edward Pickering, Alexander Rabin, Michelle Robertson, Samantha L. Rogers, Aaron H. Schneider, Anand Shah, Anays Sotolongo, Jennifer H. Therkorn, Rebecca I. Toczylowski, Matthew Watson, Alison D. Wilczynski, Ian W. Wilson, Romi A. Yount.

In the past 10 years, artificial intelligence (AI) applications have exploded in numerous fields, including medicine. Myriad publications report that the use of AI in health care is increasing, and AI has shown utility in many medical specialties, eg, pathology, radiology, and oncology.^1,2

In cancer pathology, AI was able not only to detect various cancers, but also to subtype and grade them. In addition, AI could predict survival, the success of therapeutic response, and underlying mutations from histopathologic images.³ In other medical fields, AI applications are as notable. For example, in imaging specialties like radiology, ophthalmology, dermatology, and gastroenterology, AI is being used for image recognition, enhancement, and segmentation. In addition, AI is beneficial for predicting disease progression, survival, and response to therapy in other medical specialties. Finally, AI may help with administrative tasks like scheduling.

However, many obstacles to successfully implementing AI programs in the clinical setting exist, including clinical data limitations and ethical use of data, trust in the AI models, regulatory barriers, and lack of clinical buy-in due to insufficient basic AI understanding.² To address these barriers to successful clinical AI implementation, we decided to create a formal governing body at James A. Haley Veterans’ Hospital in Tampa, Florida. Accordingly, the hospital AI committee charter was officially approved on July 22, 2021. Our model could be used by both US Department of Veterans Affairs (VA) and non-VA hospitals throughout the country.

AI Committee

The vision of the AI committee is to improve outcomes and experiences for our veterans by developing trustworthy AI capabilities to support the VA mission. The mission is to build robust capacity in AI to create and apply innovative AI solutions and transform the VA by facilitating a learning environment that supports the delivery of world-class benefits and services to our veterans. Our vision and mission are aligned with the VA National AI Institute. ⁴

The AI Committee comprises 7 subcommittees: ethics, AI clinical product evaluation, education, data sharing and acquisition, research, 3D printing, and improvement and innovation. The role of the ethics subcommittee is to ensure the ethical and equitable implementation of clinical AI. We created the ethics subcommittee guidelines based on the World Health Organization ethics and governance of AI for health documents.⁵ They include 6 basic principles: protecting human autonomy; promoting human well-being and safety and the public interest; ensuring transparency, explainability, and intelligibility; fostering responsibility and accountability; ensuring inclusiveness and equity; and promoting AI that is responsive and sustainable (Table 1).

Implementations

After a comprehensive evaluation, we implemented 2 ClearRead (Riverain Technologies) AI radiology solutions. ClearRead CT Vessel Suppress produces a secondary series of computed tomography (CT) images, suppressing vessels and other normal structures within the lungs to improve nodule detectability, and ClearRead Xray Bone Suppress, which increases the visibility of soft tissue in standard chest X-rays by suppressing the bone on the digital image without the need for 2 exposures.

The role of the education subcommittee is to educate the staff about AI and how it can improve patient care. Every Friday, we email an AI article of the week to our practitioners. In addition, we publish a newsletter, and we organize an annual AI conference. The first conference in 2022 included speakers from the National AI Institute, Moffitt Cancer Center, the University of South Florida, and our facility.

As the name indicates, the data sharing and acquisition subcommittee oversees preparing data for our clinical and research projects. The role of the research subcommittee is to coordinate and promote AI research with the ultimate goal of improving patient care.

Other Technologies

Although 3D printing does not fall under the umbrella of AI, we have decided to include it in our future-oriented AI committee. We created an online 3D printing course to promote the technology throughout the VA. We 3D print organ models to help surgeons prepare for complicated operations. In addition, together with our colleagues from the University of Florida, we used 3D printing to address the shortage of swabs for COVID-19 testing. The VA Sunshine Healthcare Network (Veterans Integrated Services Network 8) has an active Innovation and Improvement Committee. ⁹ Our improvement and innovation subcommittee serves as a coordinating body with the network committee .

Conclusions

Through the hospital AI committee, we believe that we may overcome many obstacles to successfully implementing AI applications in the clinical setting, including the ethical use of data, trust in the AI models, regulatory barriers, and lack of clinical buy-in due to insufficient basic AI knowledge.

Acknowledgments

This material is the result of work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital.

In the past 10 years, artificial intelligence (AI) applications have exploded in numerous fields, including medicine. Myriad publications report that the use of AI in health care is increasing, and AI has shown utility in many medical specialties, eg, pathology, radiology, and oncology.^1,2

In cancer pathology, AI was able not only to detect various cancers, but also to subtype and grade them. In addition, AI could predict survival, the success of therapeutic response, and underlying mutations from histopathologic images.³ In other medical fields, AI applications are as notable. For example, in imaging specialties like radiology, ophthalmology, dermatology, and gastroenterology, AI is being used for image recognition, enhancement, and segmentation. In addition, AI is beneficial for predicting disease progression, survival, and response to therapy in other medical specialties. Finally, AI may help with administrative tasks like scheduling.

However, many obstacles to successfully implementing AI programs in the clinical setting exist, including clinical data limitations and ethical use of data, trust in the AI models, regulatory barriers, and lack of clinical buy-in due to insufficient basic AI understanding.² To address these barriers to successful clinical AI implementation, we decided to create a formal governing body at James A. Haley Veterans’ Hospital in Tampa, Florida. Accordingly, the hospital AI committee charter was officially approved on July 22, 2021. Our model could be used by both US Department of Veterans Affairs (VA) and non-VA hospitals throughout the country.

AI Committee

The vision of the AI committee is to improve outcomes and experiences for our veterans by developing trustworthy AI capabilities to support the VA mission. The mission is to build robust capacity in AI to create and apply innovative AI solutions and transform the VA by facilitating a learning environment that supports the delivery of world-class benefits and services to our veterans. Our vision and mission are aligned with the VA National AI Institute. ⁴

The AI Committee comprises 7 subcommittees: ethics, AI clinical product evaluation, education, data sharing and acquisition, research, 3D printing, and improvement and innovation. The role of the ethics subcommittee is to ensure the ethical and equitable implementation of clinical AI. We created the ethics subcommittee guidelines based on the World Health Organization ethics and governance of AI for health documents.⁵ They include 6 basic principles: protecting human autonomy; promoting human well-being and safety and the public interest; ensuring transparency, explainability, and intelligibility; fostering responsibility and accountability; ensuring inclusiveness and equity; and promoting AI that is responsive and sustainable (Table 1).

Implementations

After a comprehensive evaluation, we implemented 2 ClearRead (Riverain Technologies) AI radiology solutions. ClearRead CT Vessel Suppress produces a secondary series of computed tomography (CT) images, suppressing vessels and other normal structures within the lungs to improve nodule detectability, and ClearRead Xray Bone Suppress, which increases the visibility of soft tissue in standard chest X-rays by suppressing the bone on the digital image without the need for 2 exposures.

The role of the education subcommittee is to educate the staff about AI and how it can improve patient care. Every Friday, we email an AI article of the week to our practitioners. In addition, we publish a newsletter, and we organize an annual AI conference. The first conference in 2022 included speakers from the National AI Institute, Moffitt Cancer Center, the University of South Florida, and our facility.

As the name indicates, the data sharing and acquisition subcommittee oversees preparing data for our clinical and research projects. The role of the research subcommittee is to coordinate and promote AI research with the ultimate goal of improving patient care.

Other Technologies

Although 3D printing does not fall under the umbrella of AI, we have decided to include it in our future-oriented AI committee. We created an online 3D printing course to promote the technology throughout the VA. We 3D print organ models to help surgeons prepare for complicated operations. In addition, together with our colleagues from the University of Florida, we used 3D printing to address the shortage of swabs for COVID-19 testing. The VA Sunshine Healthcare Network (Veterans Integrated Services Network 8) has an active Innovation and Improvement Committee. ⁹ Our improvement and innovation subcommittee serves as a coordinating body with the network committee .

Conclusions

Through the hospital AI committee, we believe that we may overcome many obstacles to successfully implementing AI applications in the clinical setting, including the ethical use of data, trust in the AI models, regulatory barriers, and lack of clinical buy-in due to insufficient basic AI knowledge.

Acknowledgments

This material is the result of work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital.

In the past 10 years, artificial intelligence (AI) applications have exploded in numerous fields, including medicine. Myriad publications report that the use of AI in health care is increasing, and AI has shown utility in many medical specialties, eg, pathology, radiology, and oncology.^1,2

In cancer pathology, AI was able not only to detect various cancers, but also to subtype and grade them. In addition, AI could predict survival, the success of therapeutic response, and underlying mutations from histopathologic images.³ In other medical fields, AI applications are as notable. For example, in imaging specialties like radiology, ophthalmology, dermatology, and gastroenterology, AI is being used for image recognition, enhancement, and segmentation. In addition, AI is beneficial for predicting disease progression, survival, and response to therapy in other medical specialties. Finally, AI may help with administrative tasks like scheduling.

However, many obstacles to successfully implementing AI programs in the clinical setting exist, including clinical data limitations and ethical use of data, trust in the AI models, regulatory barriers, and lack of clinical buy-in due to insufficient basic AI understanding.² To address these barriers to successful clinical AI implementation, we decided to create a formal governing body at James A. Haley Veterans’ Hospital in Tampa, Florida. Accordingly, the hospital AI committee charter was officially approved on July 22, 2021. Our model could be used by both US Department of Veterans Affairs (VA) and non-VA hospitals throughout the country.

AI Committee

The vision of the AI committee is to improve outcomes and experiences for our veterans by developing trustworthy AI capabilities to support the VA mission. The mission is to build robust capacity in AI to create and apply innovative AI solutions and transform the VA by facilitating a learning environment that supports the delivery of world-class benefits and services to our veterans. Our vision and mission are aligned with the VA National AI Institute. ⁴

The AI Committee comprises 7 subcommittees: ethics, AI clinical product evaluation, education, data sharing and acquisition, research, 3D printing, and improvement and innovation. The role of the ethics subcommittee is to ensure the ethical and equitable implementation of clinical AI. We created the ethics subcommittee guidelines based on the World Health Organization ethics and governance of AI for health documents.⁵ They include 6 basic principles: protecting human autonomy; promoting human well-being and safety and the public interest; ensuring transparency, explainability, and intelligibility; fostering responsibility and accountability; ensuring inclusiveness and equity; and promoting AI that is responsive and sustainable (Table 1).

Implementations

After a comprehensive evaluation, we implemented 2 ClearRead (Riverain Technologies) AI radiology solutions. ClearRead CT Vessel Suppress produces a secondary series of computed tomography (CT) images, suppressing vessels and other normal structures within the lungs to improve nodule detectability, and ClearRead Xray Bone Suppress, which increases the visibility of soft tissue in standard chest X-rays by suppressing the bone on the digital image without the need for 2 exposures.

The role of the education subcommittee is to educate the staff about AI and how it can improve patient care. Every Friday, we email an AI article of the week to our practitioners. In addition, we publish a newsletter, and we organize an annual AI conference. The first conference in 2022 included speakers from the National AI Institute, Moffitt Cancer Center, the University of South Florida, and our facility.

As the name indicates, the data sharing and acquisition subcommittee oversees preparing data for our clinical and research projects. The role of the research subcommittee is to coordinate and promote AI research with the ultimate goal of improving patient care.

Other Technologies

Although 3D printing does not fall under the umbrella of AI, we have decided to include it in our future-oriented AI committee. We created an online 3D printing course to promote the technology throughout the VA. We 3D print organ models to help surgeons prepare for complicated operations. In addition, together with our colleagues from the University of Florida, we used 3D printing to address the shortage of swabs for COVID-19 testing. The VA Sunshine Healthcare Network (Veterans Integrated Services Network 8) has an active Innovation and Improvement Committee. ⁹ Our improvement and innovation subcommittee serves as a coordinating body with the network committee .

Conclusions

Through the hospital AI committee, we believe that we may overcome many obstacles to successfully implementing AI applications in the clinical setting, including the ethical use of data, trust in the AI models, regulatory barriers, and lack of clinical buy-in due to insufficient basic AI knowledge.

Acknowledgments

This material is the result of work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital.

In a cross-sectional observational study of 502 Finnish patients with AD, Salava and colleagues found that severe AD was associated with older age, male sex, early age of disease onset, higher body mass index, history of smoking, concomitant asthma, palmar hyperlinearity, hand dermatitis, history of contact allergy, and history of elevated immunoglobulin E levels. Some of these findings are correlated with each other. For example, palmar hyperlinearity was previously found to be a sign associated with early-onset AD in conjunction with Filaggrin loss-of-function mutations and atopic comorbidities.^1,2 The association of AD with increased body mass index is consistent with previous studies that found associations of AD with overweight and obesity.³ In some instances, more severe AD may precede or lead to the association, eg, asthma and hand dermatitis. These results highlight the heterogeneity and complexity of AD, especially in moderate-to-severe disease.

AD is also associated with heterogeneous triggers. In clinical practice, we commonly see patients who consider food a potential trigger for AD. To better understand the role of food-triggered AD, Li and colleagues performed a retrospective study of 372 pediatric patients with AD. They found that more than half of the children with mild, moderate, and severe AD had an immunoglobulin E–mediated food allergy. Nevertheless, food-triggered AD occurred in only 3% of patients with AD. These results are doubly important because they indicate that clinicians should address food allergies to holistically improve the health of patients with AD. On the other hand, food is rarely a reproducible trigger of AD and appropriate treatment should generally not be withheld in favor of testing for food triggers of AD.

That said, it is important to address cutaneous and extra-cutaneous infections that occur in patients with AD to prevent worsening of AD and serious sequelae of infection. Indeed, Han and colleagues examined data from the Korean National Health Insurance Service, a nationwide population-based registry including 70,205 patients with AD and an unspecified number of control patients without AD. They found that AD was associated with significantly higher odds of molluscum contagiosum, impetigo, chickenpox, otitis media, eczema herpeticum, viral warts, and viral conjunctivitis. These results are consistent with previous studies from my research group showing higher rates of these and other infections.^4-8 Anecdotally, I have seen all of these occur commonly in patients with AD, and in many instances these conditions worsen the underlying AD, eg, impetigo and eczema herpeticum.

The above-mentioned studies highlight the heterogeneity and complexity of AD, especially moderate-to-severe disease. Elsawi and colleagues conducted a survey-based study of 1065 adults with AD and found that moderate-to-severe AD was associated with increased patient burden, increased time spent managing AD symptoms, and comorbid depression. In addition, time spent managing AD symptoms was in and of itself a predictor of increased patient burden. These results underscore the many unmet needs that remain in the management of AD, with substantial patient burden from inadequate treatment as well as the inherent burden from the treatments themselves.

Additional References

1.            Meng L, Wang L, Tang H, et al. Filaggrin gene mutation c.3321delA is associated with various clinical features of atopic dermatitis in the Chinese Han population. PloS One. 2014;9:e98235. Doi: 10.1371/journal.pone.0098235

2.            Weidinger S, Illig T, Baurecht H, et al. Loss-of-function variations within the filaggrin gene predispose for atopic dermatitis with allergic sensitizations. J Allergy Clin Immunol. 2006;118:214-219. Doi: 10.1016/j.jaci.2006.05.004

3.            Zhang A, Silverberg JI. Association of atopic dermatitis with being overweight and obese: a systematic review and metaanalysis. J Am Acad Dermatol. 2015;72:606-616.e4. Doi: 10.1016/j.jaad.2014.12.013

4.            Narla S, Silverberg JI. Association between childhood atopic dermatitis and cutaneous, extracutaneous and systemic infections. Br J Dermatol. 2018;178:1467-1468. Doi: 10.1111/bjd.16482

5.            Narla S, Silverberg JI. Association between atopic dermatitis and serious cutaneous, multiorgan and systemic infections in US adults. Anb Allergy Asthma Immunol. 2018;120:66-72e11. Doi: 10.1016/j.anai.2017.10.019

6.            Ren Z, Silverberg JI. Association of atopic dermatitis with bacterial, fungal, viral, and sexually transmitted skin infections. Dermatitis. 2020;31:157-164. Doi: 10.1097/DER.0000000000000526

7.            Serrano L, Patel KR, Silverberg JI. Association between atopic dermatitis and extracutaneous bacterial and mycobacterial infections: a systematic review and meta-analysis. J Acad Am Acad Dermatol. 2019;80:904-912. Doi: 10.1016/j.jaad.2018.11.028

8.            Silverberg JI, Silverberg NB. Childhood atopic dermatitis and warts are associated with increased risk of infection: a US population-based study. J Allergy Clin Immunol. 2014;133:1041-1047. Doi: 10.1016/j.jaci.2013.08.012

In a cross-sectional observational study of 502 Finnish patients with AD, Salava and colleagues found that severe AD was associated with older age, male sex, early age of disease onset, higher body mass index, history of smoking, concomitant asthma, palmar hyperlinearity, hand dermatitis, history of contact allergy, and history of elevated immunoglobulin E levels. Some of these findings are correlated with each other. For example, palmar hyperlinearity was previously found to be a sign associated with early-onset AD in conjunction with Filaggrin loss-of-function mutations and atopic comorbidities.^1,2 The association of AD with increased body mass index is consistent with previous studies that found associations of AD with overweight and obesity.³ In some instances, more severe AD may precede or lead to the association, eg, asthma and hand dermatitis. These results highlight the heterogeneity and complexity of AD, especially in moderate-to-severe disease.

AD is also associated with heterogeneous triggers. In clinical practice, we commonly see patients who consider food a potential trigger for AD. To better understand the role of food-triggered AD, Li and colleagues performed a retrospective study of 372 pediatric patients with AD. They found that more than half of the children with mild, moderate, and severe AD had an immunoglobulin E–mediated food allergy. Nevertheless, food-triggered AD occurred in only 3% of patients with AD. These results are doubly important because they indicate that clinicians should address food allergies to holistically improve the health of patients with AD. On the other hand, food is rarely a reproducible trigger of AD and appropriate treatment should generally not be withheld in favor of testing for food triggers of AD.

That said, it is important to address cutaneous and extra-cutaneous infections that occur in patients with AD to prevent worsening of AD and serious sequelae of infection. Indeed, Han and colleagues examined data from the Korean National Health Insurance Service, a nationwide population-based registry including 70,205 patients with AD and an unspecified number of control patients without AD. They found that AD was associated with significantly higher odds of molluscum contagiosum, impetigo, chickenpox, otitis media, eczema herpeticum, viral warts, and viral conjunctivitis. These results are consistent with previous studies from my research group showing higher rates of these and other infections.^4-8 Anecdotally, I have seen all of these occur commonly in patients with AD, and in many instances these conditions worsen the underlying AD, eg, impetigo and eczema herpeticum.

The above-mentioned studies highlight the heterogeneity and complexity of AD, especially moderate-to-severe disease. Elsawi and colleagues conducted a survey-based study of 1065 adults with AD and found that moderate-to-severe AD was associated with increased patient burden, increased time spent managing AD symptoms, and comorbid depression. In addition, time spent managing AD symptoms was in and of itself a predictor of increased patient burden. These results underscore the many unmet needs that remain in the management of AD, with substantial patient burden from inadequate treatment as well as the inherent burden from the treatments themselves.

Additional References

1.            Meng L, Wang L, Tang H, et al. Filaggrin gene mutation c.3321delA is associated with various clinical features of atopic dermatitis in the Chinese Han population. PloS One. 2014;9:e98235. Doi: 10.1371/journal.pone.0098235

2.            Weidinger S, Illig T, Baurecht H, et al. Loss-of-function variations within the filaggrin gene predispose for atopic dermatitis with allergic sensitizations. J Allergy Clin Immunol. 2006;118:214-219. Doi: 10.1016/j.jaci.2006.05.004

3.            Zhang A, Silverberg JI. Association of atopic dermatitis with being overweight and obese: a systematic review and metaanalysis. J Am Acad Dermatol. 2015;72:606-616.e4. Doi: 10.1016/j.jaad.2014.12.013

4.            Narla S, Silverberg JI. Association between childhood atopic dermatitis and cutaneous, extracutaneous and systemic infections. Br J Dermatol. 2018;178:1467-1468. Doi: 10.1111/bjd.16482

5.            Narla S, Silverberg JI. Association between atopic dermatitis and serious cutaneous, multiorgan and systemic infections in US adults. Anb Allergy Asthma Immunol. 2018;120:66-72e11. Doi: 10.1016/j.anai.2017.10.019

6.            Ren Z, Silverberg JI. Association of atopic dermatitis with bacterial, fungal, viral, and sexually transmitted skin infections. Dermatitis. 2020;31:157-164. Doi: 10.1097/DER.0000000000000526

7.            Serrano L, Patel KR, Silverberg JI. Association between atopic dermatitis and extracutaneous bacterial and mycobacterial infections: a systematic review and meta-analysis. J Acad Am Acad Dermatol. 2019;80:904-912. Doi: 10.1016/j.jaad.2018.11.028

8.            Silverberg JI, Silverberg NB. Childhood atopic dermatitis and warts are associated with increased risk of infection: a US population-based study. J Allergy Clin Immunol. 2014;133:1041-1047. Doi: 10.1016/j.jaci.2013.08.012

In a cross-sectional observational study of 502 Finnish patients with AD, Salava and colleagues found that severe AD was associated with older age, male sex, early age of disease onset, higher body mass index, history of smoking, concomitant asthma, palmar hyperlinearity, hand dermatitis, history of contact allergy, and history of elevated immunoglobulin E levels. Some of these findings are correlated with each other. For example, palmar hyperlinearity was previously found to be a sign associated with early-onset AD in conjunction with Filaggrin loss-of-function mutations and atopic comorbidities.^1,2 The association of AD with increased body mass index is consistent with previous studies that found associations of AD with overweight and obesity.³ In some instances, more severe AD may precede or lead to the association, eg, asthma and hand dermatitis. These results highlight the heterogeneity and complexity of AD, especially in moderate-to-severe disease.

AD is also associated with heterogeneous triggers. In clinical practice, we commonly see patients who consider food a potential trigger for AD. To better understand the role of food-triggered AD, Li and colleagues performed a retrospective study of 372 pediatric patients with AD. They found that more than half of the children with mild, moderate, and severe AD had an immunoglobulin E–mediated food allergy. Nevertheless, food-triggered AD occurred in only 3% of patients with AD. These results are doubly important because they indicate that clinicians should address food allergies to holistically improve the health of patients with AD. On the other hand, food is rarely a reproducible trigger of AD and appropriate treatment should generally not be withheld in favor of testing for food triggers of AD.

That said, it is important to address cutaneous and extra-cutaneous infections that occur in patients with AD to prevent worsening of AD and serious sequelae of infection. Indeed, Han and colleagues examined data from the Korean National Health Insurance Service, a nationwide population-based registry including 70,205 patients with AD and an unspecified number of control patients without AD. They found that AD was associated with significantly higher odds of molluscum contagiosum, impetigo, chickenpox, otitis media, eczema herpeticum, viral warts, and viral conjunctivitis. These results are consistent with previous studies from my research group showing higher rates of these and other infections.^4-8 Anecdotally, I have seen all of these occur commonly in patients with AD, and in many instances these conditions worsen the underlying AD, eg, impetigo and eczema herpeticum.

The above-mentioned studies highlight the heterogeneity and complexity of AD, especially moderate-to-severe disease. Elsawi and colleagues conducted a survey-based study of 1065 adults with AD and found that moderate-to-severe AD was associated with increased patient burden, increased time spent managing AD symptoms, and comorbid depression. In addition, time spent managing AD symptoms was in and of itself a predictor of increased patient burden. These results underscore the many unmet needs that remain in the management of AD, with substantial patient burden from inadequate treatment as well as the inherent burden from the treatments themselves.

Additional References

1.            Meng L, Wang L, Tang H, et al. Filaggrin gene mutation c.3321delA is associated with various clinical features of atopic dermatitis in the Chinese Han population. PloS One. 2014;9:e98235. Doi: 10.1371/journal.pone.0098235

2.            Weidinger S, Illig T, Baurecht H, et al. Loss-of-function variations within the filaggrin gene predispose for atopic dermatitis with allergic sensitizations. J Allergy Clin Immunol. 2006;118:214-219. Doi: 10.1016/j.jaci.2006.05.004

3.            Zhang A, Silverberg JI. Association of atopic dermatitis with being overweight and obese: a systematic review and metaanalysis. J Am Acad Dermatol. 2015;72:606-616.e4. Doi: 10.1016/j.jaad.2014.12.013

4.            Narla S, Silverberg JI. Association between childhood atopic dermatitis and cutaneous, extracutaneous and systemic infections. Br J Dermatol. 2018;178:1467-1468. Doi: 10.1111/bjd.16482

5.            Narla S, Silverberg JI. Association between atopic dermatitis and serious cutaneous, multiorgan and systemic infections in US adults. Anb Allergy Asthma Immunol. 2018;120:66-72e11. Doi: 10.1016/j.anai.2017.10.019

6.            Ren Z, Silverberg JI. Association of atopic dermatitis with bacterial, fungal, viral, and sexually transmitted skin infections. Dermatitis. 2020;31:157-164. Doi: 10.1097/DER.0000000000000526

7.            Serrano L, Patel KR, Silverberg JI. Association between atopic dermatitis and extracutaneous bacterial and mycobacterial infections: a systematic review and meta-analysis. J Acad Am Acad Dermatol. 2019;80:904-912. Doi: 10.1016/j.jaad.2018.11.028

8.            Silverberg JI, Silverberg NB. Childhood atopic dermatitis and warts are associated with increased risk of infection: a US population-based study. J Allergy Clin Immunol. 2014;133:1041-1047. Doi: 10.1016/j.jaci.2013.08.012

The major classifications of thyroid disease include hyperthyroidism, which is seen in Graves disease, and hypothyroidism due to iodine deficiency and Hashimoto thyroiditis, which have potentially devastating health consequences. The prevalence of hyperthyroidism ranges from 0.2% to 1.3% in iodine-sufficient parts of the world, and the prevalence of hypothyroidism in the general population is 5.3% in Europe and 3.7% in the United States.¹ Thyroid hormones physiologically potentiate α- and β-adrenergic receptors by increasing their sensitivity to catecholamines. Excess thyroid hormones manifest as tachycardia, increased cardiac output, increased body temperature, hyperhidrosis, and warm moist skin. Reduced sensitivity of adrenergic receptors to catecholamines from insufficient thyroid hormones results in a lower metabolic rate and decreases response to the sympathetic nervous system.² Nail changes in thyroid patients have not been well studied.³ Our objectives were to characterize nail findings in patients with thyroid disease. Early diagnosis of thyroid disease and prompt referral for treatment may be instrumental in preventing serious morbidities and permanent sequelae.

Methods

PubMed, Scopus, Web of Science, and Google Scholar were searched for the terms nail + thyroid, nail + hyperthyroid, nail + hypothyroid, nail + Graves, and nail + Hashimoto on June 10, 2020, and then updated on November 18, 2020. All English-language articles were included. Non–English-language articles and those that did not describe clinical trials of nail changes in patients with thyroid disease were excluded. One study that utilized survey-based data for nail changes without corroboration with physical examination findings was excluded. Hypothyroidism/hyperthyroidism was defined by all authors as measurement of serum thyroid hormones triiodothyronine, thyroxine, and thyroid-stimulating hormone outside of the normal range. Eight studies were included in the final analysis. Patient demographics, thyroid disease type, physical examination findings, nail clinical findings, age at diagnosis, age at onset of nail changes, treatments/medications, and comorbidities were recorded and analyzed.

Results

Nail changes in patients with thyroid disease were reported in 8 studies (7 cross-sectional, 1 retrospective cohort) and are summarized in the Table.^4-11 The mean age was 41.2 years (range, 5–80 years), with a higher representation of females (range, 70%–94% female). The most common nail changes in thyroid patients were koilonychia, clubbing, and nail brittleness. Other changes included onycholysis, thin nails, dryness, and changes in nail growth rate. Frequent physical findings were xerosis, pruritus, and alopecia.

Both koilonychia and clubbing were reported in patients with hyperthyroidism. In a study of 32 patients with koilonychia, 22 (68.8%) were diagnosed with hyperthyroidism.¹⁰ Nail clubbing affected 7.3% of Graves disease patients (n=150)⁶ and 5.0% of hyperthyroid patients (n=120).⁷ Dermopathy presented more than 1 year after diagnosis of Graves disease in 99 (66%) of 150 patients as a late manifestation of thyrotoxicosis.⁶ Additional physical features in patients with Graves disease (n=150) were pretibial myxedema (100%), ophthalmopathy (99.0%), and proptosis (88.0%). Non–Graves hyperthyroid patients showed physical features of soft hair (83.3%) and soft skin (66.0%).⁷

Nail brittleness was a frequently reported nail change in thyroid patients (4/8 studies, 50%), most often seen in 22% of autoimmune patients, 19.6% of nonautoimmune patients, 13.9% of hypothyroid patients, and 9.2% of hyperthyroid patients.^5,8 For comparison, brittle nails presented in 10.8% of participants in a control group.⁵ Brittle nails in thyroid patients often are accompanied by other nail findings such as thinning, onycholysis, and pitting.

Among hypothyroid patients, nail changes included fragility (70%; n=50), slow growth (48%; n=50), thinning (40%; n=50), onycholysis (38%; n=50),⁷ and brittleness (13.9%; n=173).⁵ Less common nail changes in hypothyroid patients were leukonychia (9.4%; n=32), striped nails (6%; n=50), and pitting (1.2%; n=173).^5,7,11 Among hyperthyroid patients, the most common nail changes were koilonychia (100%; n=22), softening (83%; n=120), onycholysis (29%; n=14), and brittleness (9.2%; n=173).^5,7,9,10 Less common nail changes in hyperthyroid patients were clubbing (5%; n=120), thinning (4.6%; n=173), and leukonychia (3%; n=120).^5,7

Additional cutaneous findings of thyroid disorder included xerosis, alopecia, pruritus, and weight change. Xerosis was most common in hypothyroid disease (57.2%; n=460).⁴ In 2 studies,^8,9 alopecia affected approximately 70% of autoimmune, nonautoimmune, and hyperthyroid patients. Hair loss was reported in 42.6% (n=460)⁴ and 33.0% (n=36)⁹ of hypothyroid patients. Additionally, pruritus affected up to 28% (n=32)¹¹ of hypothyroid and 16.0% (n=120)⁷ of hyperthyroid patients and was more common in autoimmune (41%) vs nonautoimmune (32%) thyroid patients.⁸ Weight gain was seen in 72% of hypothyroid patients (n=32),¹¹ and soft hair and skin were reported in 83.3% and 66% of hyperthyroid patients (n=120), respectively.⁷ Flushing was a less common physical finding in thyroid patients (usually affecting <10%); however, it also was reported in 17.1% of autoimmune and 57.1% of hyperthyroid patients from 2 separate studies.^8,9

There are limited data describing nail changes with thyroid disease. Singal and Arora³ reported in their clinical review of nail changes in systemic disease that koilonychia, onycholysis, and melanonychia are associated with thyroid disorders. We similarly found that koilonychia and onycholysis are associated with thyroid disorders without an association with melanonychia.

In his clinical review of thyroid hormone action on the skin, Safer¹² described hypothyroid patients having coarse, dull, thin, and brittle nails, whereas in thyrotoxicosis, patients had shiny, soft, and concave nails with onycholysis; however, the author commented that there were limited data on the clinical findings in thyroid disorders. These nail findings are consistent with our results, but onycholysis was more common in hypothyroid patients than in hyperthyroid patients in our review. Fox¹³ reported on 30 cases of onycholysis, stating that it affected patients with hypothyroidism and improved with thyroid treatment. In a clinical review of 8 commonly seen nail abnormalities, Fowler et al¹⁴ reported that hyperthyroidism was associated with nail findings in 5% of cases and may result in onycholysis of the fourth and fifth nails or all nails. They also reported that onychorrhexis may be seen in patients with hypothyroidism, a finding that differed from our results.¹⁴

The mechanism of nail changes in thyroid disease has not been well studied. A protein/amino acid–deficiency state may contribute to the development of koilonychia. Hyperthyroid patients, who have high metabolic activity, may have hypoalbuminemia, leading to koilonychia.¹⁵ Hypothyroidism causes hypothermia from decreased metabolic rate and secondary compensatory vasoconstriction. Vasoconstriction decreases blood flow of nutrients and oxygen to cutaneous structures and may cause slow-growing, brittle nails. In hyperthyroidism, vasodilation alternatively may contribute to the fast-growing nails. Anti–thyroid-stimulating hormone receptor antibodies in Graves disease may increase the synthesis of hyaluronic acid and glycosaminoglycans from fibroblasts, keratinocytes, adipocytes, or endothelial cells in the dermis and may contribute to development of clubbing.¹⁶

Our review is subject to several limitations. We recorded nail findings as they were described in the original studies; however, we could not confirm the accuracy of these descriptions. In addition, some specific nail changes were not described in sufficient detail. In all but 1 study, dermatologists performed the physical examination. In the study by Al-Dabbagh and Al-Abachi,¹⁰ the physical examinations were performed by general medicine physicians, but they selected only for patients with koilonychia and did not assess for other skin findings. Fragile nails and brittle nails were described in hypothyroid and hyperthyroid patients, but these nail changes were not described in detail. There also were studies describing nail changes in thyroid patients; some studies had small numbers of patients, and many did not have a control group.

Conclusion

Nail changes may be early clinical presenting signs of thyroid disorders and may be the clue to prompt diagnosis of thyroid disease. Dermatologists should be mindful that fragile, slow-growing, thin nails and onycholysis are associated with hypothyroidism and that koilonychia, softening, onycholysis, and brittle nail changes may be seen in hyperthyroidism. Our review aimed to describe nail changes associated with thyroid disease to guide dermatologists on diagnosis and promote future research on dermatologic manifestations of thyroid disease. Future research is necessary to explore the association between koilonychia and hyperthyroidism as well as the association of nail changes with thyroid disease duration and severity.

The major classifications of thyroid disease include hyperthyroidism, which is seen in Graves disease, and hypothyroidism due to iodine deficiency and Hashimoto thyroiditis, which have potentially devastating health consequences. The prevalence of hyperthyroidism ranges from 0.2% to 1.3% in iodine-sufficient parts of the world, and the prevalence of hypothyroidism in the general population is 5.3% in Europe and 3.7% in the United States.¹ Thyroid hormones physiologically potentiate α- and β-adrenergic receptors by increasing their sensitivity to catecholamines. Excess thyroid hormones manifest as tachycardia, increased cardiac output, increased body temperature, hyperhidrosis, and warm moist skin. Reduced sensitivity of adrenergic receptors to catecholamines from insufficient thyroid hormones results in a lower metabolic rate and decreases response to the sympathetic nervous system.² Nail changes in thyroid patients have not been well studied.³ Our objectives were to characterize nail findings in patients with thyroid disease. Early diagnosis of thyroid disease and prompt referral for treatment may be instrumental in preventing serious morbidities and permanent sequelae.

Methods

PubMed, Scopus, Web of Science, and Google Scholar were searched for the terms nail + thyroid, nail + hyperthyroid, nail + hypothyroid, nail + Graves, and nail + Hashimoto on June 10, 2020, and then updated on November 18, 2020. All English-language articles were included. Non–English-language articles and those that did not describe clinical trials of nail changes in patients with thyroid disease were excluded. One study that utilized survey-based data for nail changes without corroboration with physical examination findings was excluded. Hypothyroidism/hyperthyroidism was defined by all authors as measurement of serum thyroid hormones triiodothyronine, thyroxine, and thyroid-stimulating hormone outside of the normal range. Eight studies were included in the final analysis. Patient demographics, thyroid disease type, physical examination findings, nail clinical findings, age at diagnosis, age at onset of nail changes, treatments/medications, and comorbidities were recorded and analyzed.

Results

Nail changes in patients with thyroid disease were reported in 8 studies (7 cross-sectional, 1 retrospective cohort) and are summarized in the Table.^4-11 The mean age was 41.2 years (range, 5–80 years), with a higher representation of females (range, 70%–94% female). The most common nail changes in thyroid patients were koilonychia, clubbing, and nail brittleness. Other changes included onycholysis, thin nails, dryness, and changes in nail growth rate. Frequent physical findings were xerosis, pruritus, and alopecia.

Both koilonychia and clubbing were reported in patients with hyperthyroidism. In a study of 32 patients with koilonychia, 22 (68.8%) were diagnosed with hyperthyroidism.¹⁰ Nail clubbing affected 7.3% of Graves disease patients (n=150)⁶ and 5.0% of hyperthyroid patients (n=120).⁷ Dermopathy presented more than 1 year after diagnosis of Graves disease in 99 (66%) of 150 patients as a late manifestation of thyrotoxicosis.⁶ Additional physical features in patients with Graves disease (n=150) were pretibial myxedema (100%), ophthalmopathy (99.0%), and proptosis (88.0%). Non–Graves hyperthyroid patients showed physical features of soft hair (83.3%) and soft skin (66.0%).⁷

Nail brittleness was a frequently reported nail change in thyroid patients (4/8 studies, 50%), most often seen in 22% of autoimmune patients, 19.6% of nonautoimmune patients, 13.9% of hypothyroid patients, and 9.2% of hyperthyroid patients.^5,8 For comparison, brittle nails presented in 10.8% of participants in a control group.⁵ Brittle nails in thyroid patients often are accompanied by other nail findings such as thinning, onycholysis, and pitting.

Among hypothyroid patients, nail changes included fragility (70%; n=50), slow growth (48%; n=50), thinning (40%; n=50), onycholysis (38%; n=50),⁷ and brittleness (13.9%; n=173).⁵ Less common nail changes in hypothyroid patients were leukonychia (9.4%; n=32), striped nails (6%; n=50), and pitting (1.2%; n=173).^5,7,11 Among hyperthyroid patients, the most common nail changes were koilonychia (100%; n=22), softening (83%; n=120), onycholysis (29%; n=14), and brittleness (9.2%; n=173).^5,7,9,10 Less common nail changes in hyperthyroid patients were clubbing (5%; n=120), thinning (4.6%; n=173), and leukonychia (3%; n=120).^5,7

Additional cutaneous findings of thyroid disorder included xerosis, alopecia, pruritus, and weight change. Xerosis was most common in hypothyroid disease (57.2%; n=460).⁴ In 2 studies,^8,9 alopecia affected approximately 70% of autoimmune, nonautoimmune, and hyperthyroid patients. Hair loss was reported in 42.6% (n=460)⁴ and 33.0% (n=36)⁹ of hypothyroid patients. Additionally, pruritus affected up to 28% (n=32)¹¹ of hypothyroid and 16.0% (n=120)⁷ of hyperthyroid patients and was more common in autoimmune (41%) vs nonautoimmune (32%) thyroid patients.⁸ Weight gain was seen in 72% of hypothyroid patients (n=32),¹¹ and soft hair and skin were reported in 83.3% and 66% of hyperthyroid patients (n=120), respectively.⁷ Flushing was a less common physical finding in thyroid patients (usually affecting <10%); however, it also was reported in 17.1% of autoimmune and 57.1% of hyperthyroid patients from 2 separate studies.^8,9

There are limited data describing nail changes with thyroid disease. Singal and Arora³ reported in their clinical review of nail changes in systemic disease that koilonychia, onycholysis, and melanonychia are associated with thyroid disorders. We similarly found that koilonychia and onycholysis are associated with thyroid disorders without an association with melanonychia.

In his clinical review of thyroid hormone action on the skin, Safer¹² described hypothyroid patients having coarse, dull, thin, and brittle nails, whereas in thyrotoxicosis, patients had shiny, soft, and concave nails with onycholysis; however, the author commented that there were limited data on the clinical findings in thyroid disorders. These nail findings are consistent with our results, but onycholysis was more common in hypothyroid patients than in hyperthyroid patients in our review. Fox¹³ reported on 30 cases of onycholysis, stating that it affected patients with hypothyroidism and improved with thyroid treatment. In a clinical review of 8 commonly seen nail abnormalities, Fowler et al¹⁴ reported that hyperthyroidism was associated with nail findings in 5% of cases and may result in onycholysis of the fourth and fifth nails or all nails. They also reported that onychorrhexis may be seen in patients with hypothyroidism, a finding that differed from our results.¹⁴

The mechanism of nail changes in thyroid disease has not been well studied. A protein/amino acid–deficiency state may contribute to the development of koilonychia. Hyperthyroid patients, who have high metabolic activity, may have hypoalbuminemia, leading to koilonychia.¹⁵ Hypothyroidism causes hypothermia from decreased metabolic rate and secondary compensatory vasoconstriction. Vasoconstriction decreases blood flow of nutrients and oxygen to cutaneous structures and may cause slow-growing, brittle nails. In hyperthyroidism, vasodilation alternatively may contribute to the fast-growing nails. Anti–thyroid-stimulating hormone receptor antibodies in Graves disease may increase the synthesis of hyaluronic acid and glycosaminoglycans from fibroblasts, keratinocytes, adipocytes, or endothelial cells in the dermis and may contribute to development of clubbing.¹⁶

Our review is subject to several limitations. We recorded nail findings as they were described in the original studies; however, we could not confirm the accuracy of these descriptions. In addition, some specific nail changes were not described in sufficient detail. In all but 1 study, dermatologists performed the physical examination. In the study by Al-Dabbagh and Al-Abachi,¹⁰ the physical examinations were performed by general medicine physicians, but they selected only for patients with koilonychia and did not assess for other skin findings. Fragile nails and brittle nails were described in hypothyroid and hyperthyroid patients, but these nail changes were not described in detail. There also were studies describing nail changes in thyroid patients; some studies had small numbers of patients, and many did not have a control group.

Conclusion

Nail changes may be early clinical presenting signs of thyroid disorders and may be the clue to prompt diagnosis of thyroid disease. Dermatologists should be mindful that fragile, slow-growing, thin nails and onycholysis are associated with hypothyroidism and that koilonychia, softening, onycholysis, and brittle nail changes may be seen in hyperthyroidism. Our review aimed to describe nail changes associated with thyroid disease to guide dermatologists on diagnosis and promote future research on dermatologic manifestations of thyroid disease. Future research is necessary to explore the association between koilonychia and hyperthyroidism as well as the association of nail changes with thyroid disease duration and severity.

The major classifications of thyroid disease include hyperthyroidism, which is seen in Graves disease, and hypothyroidism due to iodine deficiency and Hashimoto thyroiditis, which have potentially devastating health consequences. The prevalence of hyperthyroidism ranges from 0.2% to 1.3% in iodine-sufficient parts of the world, and the prevalence of hypothyroidism in the general population is 5.3% in Europe and 3.7% in the United States.¹ Thyroid hormones physiologically potentiate α- and β-adrenergic receptors by increasing their sensitivity to catecholamines. Excess thyroid hormones manifest as tachycardia, increased cardiac output, increased body temperature, hyperhidrosis, and warm moist skin. Reduced sensitivity of adrenergic receptors to catecholamines from insufficient thyroid hormones results in a lower metabolic rate and decreases response to the sympathetic nervous system.² Nail changes in thyroid patients have not been well studied.³ Our objectives were to characterize nail findings in patients with thyroid disease. Early diagnosis of thyroid disease and prompt referral for treatment may be instrumental in preventing serious morbidities and permanent sequelae.

Methods

PubMed, Scopus, Web of Science, and Google Scholar were searched for the terms nail + thyroid, nail + hyperthyroid, nail + hypothyroid, nail + Graves, and nail + Hashimoto on June 10, 2020, and then updated on November 18, 2020. All English-language articles were included. Non–English-language articles and those that did not describe clinical trials of nail changes in patients with thyroid disease were excluded. One study that utilized survey-based data for nail changes without corroboration with physical examination findings was excluded. Hypothyroidism/hyperthyroidism was defined by all authors as measurement of serum thyroid hormones triiodothyronine, thyroxine, and thyroid-stimulating hormone outside of the normal range. Eight studies were included in the final analysis. Patient demographics, thyroid disease type, physical examination findings, nail clinical findings, age at diagnosis, age at onset of nail changes, treatments/medications, and comorbidities were recorded and analyzed.

Results

Nail changes in patients with thyroid disease were reported in 8 studies (7 cross-sectional, 1 retrospective cohort) and are summarized in the Table.^4-11 The mean age was 41.2 years (range, 5–80 years), with a higher representation of females (range, 70%–94% female). The most common nail changes in thyroid patients were koilonychia, clubbing, and nail brittleness. Other changes included onycholysis, thin nails, dryness, and changes in nail growth rate. Frequent physical findings were xerosis, pruritus, and alopecia.

Both koilonychia and clubbing were reported in patients with hyperthyroidism. In a study of 32 patients with koilonychia, 22 (68.8%) were diagnosed with hyperthyroidism.¹⁰ Nail clubbing affected 7.3% of Graves disease patients (n=150)⁶ and 5.0% of hyperthyroid patients (n=120).⁷ Dermopathy presented more than 1 year after diagnosis of Graves disease in 99 (66%) of 150 patients as a late manifestation of thyrotoxicosis.⁶ Additional physical features in patients with Graves disease (n=150) were pretibial myxedema (100%), ophthalmopathy (99.0%), and proptosis (88.0%). Non–Graves hyperthyroid patients showed physical features of soft hair (83.3%) and soft skin (66.0%).⁷

Nail brittleness was a frequently reported nail change in thyroid patients (4/8 studies, 50%), most often seen in 22% of autoimmune patients, 19.6% of nonautoimmune patients, 13.9% of hypothyroid patients, and 9.2% of hyperthyroid patients.^5,8 For comparison, brittle nails presented in 10.8% of participants in a control group.⁵ Brittle nails in thyroid patients often are accompanied by other nail findings such as thinning, onycholysis, and pitting.

Among hypothyroid patients, nail changes included fragility (70%; n=50), slow growth (48%; n=50), thinning (40%; n=50), onycholysis (38%; n=50),⁷ and brittleness (13.9%; n=173).⁵ Less common nail changes in hypothyroid patients were leukonychia (9.4%; n=32), striped nails (6%; n=50), and pitting (1.2%; n=173).^5,7,11 Among hyperthyroid patients, the most common nail changes were koilonychia (100%; n=22), softening (83%; n=120), onycholysis (29%; n=14), and brittleness (9.2%; n=173).^5,7,9,10 Less common nail changes in hyperthyroid patients were clubbing (5%; n=120), thinning (4.6%; n=173), and leukonychia (3%; n=120).^5,7

Additional cutaneous findings of thyroid disorder included xerosis, alopecia, pruritus, and weight change. Xerosis was most common in hypothyroid disease (57.2%; n=460).⁴ In 2 studies,^8,9 alopecia affected approximately 70% of autoimmune, nonautoimmune, and hyperthyroid patients. Hair loss was reported in 42.6% (n=460)⁴ and 33.0% (n=36)⁹ of hypothyroid patients. Additionally, pruritus affected up to 28% (n=32)¹¹ of hypothyroid and 16.0% (n=120)⁷ of hyperthyroid patients and was more common in autoimmune (41%) vs nonautoimmune (32%) thyroid patients.⁸ Weight gain was seen in 72% of hypothyroid patients (n=32),¹¹ and soft hair and skin were reported in 83.3% and 66% of hyperthyroid patients (n=120), respectively.⁷ Flushing was a less common physical finding in thyroid patients (usually affecting <10%); however, it also was reported in 17.1% of autoimmune and 57.1% of hyperthyroid patients from 2 separate studies.^8,9

There are limited data describing nail changes with thyroid disease. Singal and Arora³ reported in their clinical review of nail changes in systemic disease that koilonychia, onycholysis, and melanonychia are associated with thyroid disorders. We similarly found that koilonychia and onycholysis are associated with thyroid disorders without an association with melanonychia.

In his clinical review of thyroid hormone action on the skin, Safer¹² described hypothyroid patients having coarse, dull, thin, and brittle nails, whereas in thyrotoxicosis, patients had shiny, soft, and concave nails with onycholysis; however, the author commented that there were limited data on the clinical findings in thyroid disorders. These nail findings are consistent with our results, but onycholysis was more common in hypothyroid patients than in hyperthyroid patients in our review. Fox¹³ reported on 30 cases of onycholysis, stating that it affected patients with hypothyroidism and improved with thyroid treatment. In a clinical review of 8 commonly seen nail abnormalities, Fowler et al¹⁴ reported that hyperthyroidism was associated with nail findings in 5% of cases and may result in onycholysis of the fourth and fifth nails or all nails. They also reported that onychorrhexis may be seen in patients with hypothyroidism, a finding that differed from our results.¹⁴

The mechanism of nail changes in thyroid disease has not been well studied. A protein/amino acid–deficiency state may contribute to the development of koilonychia. Hyperthyroid patients, who have high metabolic activity, may have hypoalbuminemia, leading to koilonychia.¹⁵ Hypothyroidism causes hypothermia from decreased metabolic rate and secondary compensatory vasoconstriction. Vasoconstriction decreases blood flow of nutrients and oxygen to cutaneous structures and may cause slow-growing, brittle nails. In hyperthyroidism, vasodilation alternatively may contribute to the fast-growing nails. Anti–thyroid-stimulating hormone receptor antibodies in Graves disease may increase the synthesis of hyaluronic acid and glycosaminoglycans from fibroblasts, keratinocytes, adipocytes, or endothelial cells in the dermis and may contribute to development of clubbing.¹⁶

Our review is subject to several limitations. We recorded nail findings as they were described in the original studies; however, we could not confirm the accuracy of these descriptions. In addition, some specific nail changes were not described in sufficient detail. In all but 1 study, dermatologists performed the physical examination. In the study by Al-Dabbagh and Al-Abachi,¹⁰ the physical examinations were performed by general medicine physicians, but they selected only for patients with koilonychia and did not assess for other skin findings. Fragile nails and brittle nails were described in hypothyroid and hyperthyroid patients, but these nail changes were not described in detail. There also were studies describing nail changes in thyroid patients; some studies had small numbers of patients, and many did not have a control group.

Conclusion

Nail changes may be early clinical presenting signs of thyroid disorders and may be the clue to prompt diagnosis of thyroid disease. Dermatologists should be mindful that fragile, slow-growing, thin nails and onycholysis are associated with hypothyroidism and that koilonychia, softening, onycholysis, and brittle nail changes may be seen in hyperthyroidism. Our review aimed to describe nail changes associated with thyroid disease to guide dermatologists on diagnosis and promote future research on dermatologic manifestations of thyroid disease. Future research is necessary to explore the association between koilonychia and hyperthyroidism as well as the association of nail changes with thyroid disease duration and severity.

The Cutis Editorial Board is now accepting applications for the 2023 Resident Corner column. The Editorial Board will select 2 to 3 residents to serve as the Resident Corner columnists for 1 year. Articles are posted online only at www.mdedge.com/dermatology but will be referenced in Index Medicus. All applicants must be current residents and will be in residency throughout 2023.

For consideration, send your curriculum vitae along with a brief (not to exceed 500 words) statement of why you enjoy Cutis and what you can offer your fellow residents in contributing a monthly column.

A signed letter of recommendation from the Director of the dermatology residency program also should be supplied.

All materials should be submitted via email to Melissa Sears ([email protected]) by October 28. The residents who are selected to write the column for the upcoming year will be notified by November 4.

We look forward to continuing to educate dermatology residents on topics that are most important to them!

The Cutis Editorial Board is now accepting applications for the 2023 Resident Corner column. The Editorial Board will select 2 to 3 residents to serve as the Resident Corner columnists for 1 year. Articles are posted online only at www.mdedge.com/dermatology but will be referenced in Index Medicus. All applicants must be current residents and will be in residency throughout 2023.

For consideration, send your curriculum vitae along with a brief (not to exceed 500 words) statement of why you enjoy Cutis and what you can offer your fellow residents in contributing a monthly column.

A signed letter of recommendation from the Director of the dermatology residency program also should be supplied.

All materials should be submitted via email to Melissa Sears ([email protected]) by October 28. The residents who are selected to write the column for the upcoming year will be notified by November 4.

We look forward to continuing to educate dermatology residents on topics that are most important to them!

The Cutis Editorial Board is now accepting applications for the 2023 Resident Corner column. The Editorial Board will select 2 to 3 residents to serve as the Resident Corner columnists for 1 year. Articles are posted online only at www.mdedge.com/dermatology but will be referenced in Index Medicus. All applicants must be current residents and will be in residency throughout 2023.

For consideration, send your curriculum vitae along with a brief (not to exceed 500 words) statement of why you enjoy Cutis and what you can offer your fellow residents in contributing a monthly column.

A signed letter of recommendation from the Director of the dermatology residency program also should be supplied.

All materials should be submitted via email to Melissa Sears ([email protected]) by October 28. The residents who are selected to write the column for the upcoming year will be notified by November 4.

We look forward to continuing to educate dermatology residents on topics that are most important to them!

A 4-mm punch biopsy confirmed that this was a case of blaschkitis. This uncommon condition is referred to as adult blaschkitis because it resembles lichen striatus, a linear erythematous papular eruption usually seen in children younger than 15 years of age that erupts along Blaschko lines. The biopsy in this case helped to rule out lichen planus, which can also manifest with an erythematous papular eruption along Blaschko lines.

Adult blaschkitis is thought to be a hypersensitivity reaction involving T cells. It has been linked to medication use, insect stings, trauma, and autoimmune disease.¹ The characteristic linear pattern is due to the inflammatory response following the Blaschko lines of keratinocytes that migrated during the embryonic phase.¹ Post-inflammatory hyperpigmentation is a frequent complication. Topical steroids often help with the itching, but do not usually make the lesions go away. There have been better results in reducing itching and lesion prominence with intralesional steroid injections, topical calcipotriol, or calcineurin inhibitors.¹ The inflammation usually spontaneously resolves over 3 to 12 months.

The patient was advised that the condition is benign and would likely resolve on its own over time. She was counseled that since the clobetasol was helping with her itching, she could use it (sparingly) as needed. She was cautioned that prolonged usage could lead to skin atrophy.

‌

Photo courtesy of Daniel Stulberg, MD. Text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

A 4-mm punch biopsy confirmed that this was a case of blaschkitis. This uncommon condition is referred to as adult blaschkitis because it resembles lichen striatus, a linear erythematous papular eruption usually seen in children younger than 15 years of age that erupts along Blaschko lines. The biopsy in this case helped to rule out lichen planus, which can also manifest with an erythematous papular eruption along Blaschko lines.

Adult blaschkitis is thought to be a hypersensitivity reaction involving T cells. It has been linked to medication use, insect stings, trauma, and autoimmune disease.¹ The characteristic linear pattern is due to the inflammatory response following the Blaschko lines of keratinocytes that migrated during the embryonic phase.¹ Post-inflammatory hyperpigmentation is a frequent complication. Topical steroids often help with the itching, but do not usually make the lesions go away. There have been better results in reducing itching and lesion prominence with intralesional steroid injections, topical calcipotriol, or calcineurin inhibitors.¹ The inflammation usually spontaneously resolves over 3 to 12 months.

The patient was advised that the condition is benign and would likely resolve on its own over time. She was counseled that since the clobetasol was helping with her itching, she could use it (sparingly) as needed. She was cautioned that prolonged usage could lead to skin atrophy.

‌

Photo courtesy of Daniel Stulberg, MD. Text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

A 4-mm punch biopsy confirmed that this was a case of blaschkitis. This uncommon condition is referred to as adult blaschkitis because it resembles lichen striatus, a linear erythematous papular eruption usually seen in children younger than 15 years of age that erupts along Blaschko lines. The biopsy in this case helped to rule out lichen planus, which can also manifest with an erythematous papular eruption along Blaschko lines.

Adult blaschkitis is thought to be a hypersensitivity reaction involving T cells. It has been linked to medication use, insect stings, trauma, and autoimmune disease.¹ The characteristic linear pattern is due to the inflammatory response following the Blaschko lines of keratinocytes that migrated during the embryonic phase.¹ Post-inflammatory hyperpigmentation is a frequent complication. Topical steroids often help with the itching, but do not usually make the lesions go away. There have been better results in reducing itching and lesion prominence with intralesional steroid injections, topical calcipotriol, or calcineurin inhibitors.¹ The inflammation usually spontaneously resolves over 3 to 12 months.

The patient was advised that the condition is benign and would likely resolve on its own over time. She was counseled that since the clobetasol was helping with her itching, she could use it (sparingly) as needed. She was cautioned that prolonged usage could lead to skin atrophy.

‌

Photo courtesy of Daniel Stulberg, MD. Text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

Community service (CS) or service learning in dermatology (eg, free skin cancer screenings, providing care through free clinics, free teledermatology consultations) is instrumental in mitigating disparities and improving access to equitable dermatologic care. With the rate of underinsured and uninsured patients on the rise, free and federally qualified clinics frequently are the sole means by which patients access specialty care such as dermatology.¹ Contributing to the economic gap in access, the geographic disparity of dermatologists in the United States continues to climb, and many marginalized communities remain without dermatologists.² Nearly 30% of the total US population resides in geographic areas that are underserved by dermatologists, while there appears to be an oversupply of dermatologists in urban areas.³ Dermatologists practicing in rural areas make up only 10% of the dermatology workforce,⁴ whereas 40% of all dermatologists practice in the most densely populated US cities.⁵ Consequently, patients in these underserved communities face longer wait times⁶ and are less likely to utilize dermatology services than patients in dermatologist-dense geographic areas.⁷

Service opportunities have become increasingly integrated into graduate medical education.⁸ These service activities help bridge the health care access gap while fulfilling Accreditation Council of Graduate Medical Education (ACGME) requirements. Our study assessed the importance of CS to dermatology residency program directors (PDs), dermatology residents, and recent dermatology residency graduates. Herein, we describe the perceptions of CS within dermatology residency training among PDs and residents.

Methods

In this study, CS is defined as participation in activities to increase dermatologic access, education, and resources to underserved communities. Using the approved Association of Professors of Dermatology listserve and direct email communication, we surveyed 142 PDs of ACGME-accredited dermatology residency training programs. The deidentified respondents voluntarily completed a 17-question Qualtrics survey with a 5-point Likert scale (extremely, very, moderately, slightly, or not at all), yes/no/undecided, and qualitative responses.

We also surveyed current dermatology residents and recent graduates of ACGME-accredited dermatology residency programs via PDs nationwide. The deidentified respondents voluntarily completed a 19-question Qualtrics survey with a 5-point Likert scale (extremely, very, moderately, slightly, or not at all), yes/no/undecided, and qualitative responses.

Descriptive statistics were used for data analysis for both Qualtrics surveys. The University of Pittsburgh institutional review board deemed this study exempt.

Results

Feedback From PDs—Of the 142 PDs, we received 78 responses (54.9%). For selection of dermatology residents, CS was moderately to extremely important to 64 (82.1%) PDs, and 63 (80.8%) PDs stated CS was moderately to extremely important to their dermatology residency program at large. For dermatology residency training, 66 (84.6%) PDs believed CS is important, whereas 3 (3.8%) believed it is not important, and 9 (11.5%) remained undecided (Figure 1). Notably, 17 (21.8%) programs required CS as part of the dermatology educational curriculum, with most of these programs requiring 10 hours or less during the 3 years of residency training. Of the programs with required CS, 15 (88.2%) had dermatology-specific CS requirements, with 10 (58.8%) programs involved in CS at free and/or underserved clinics and some programs participating in other CS activities, such as advocacy, mentorship, educational outreach, or sports (Figure 2A).

Community service opportunities were offered to dermatology residents by 69 (88.5%) programs, including the 17 programs that required CS as part of the dermatology educational curriculum. Among these programs with optional CS, 43 (82.7%) PDs reported CS opportunities at free and/or underserved clinics, and 30 (57.7%) reported CS opportunities through global health initiatives (Figure 2B). Other CS opportunities offered included partnerships with community outreach organizations and mentoring underprivileged students. Patient populations that benefit from CS offered by these dermatology residency programs included 55 (79.7%) underserved, 33 (47.8%) minority, 31 (44.9%) immigrant, 14 (20.3%) pediatric, 14 (20.3%) elderly, and 10 (14.5%) rural populations (Figure 2C). At dermatology residency programs with optional CS opportunities, 22 (42.3%) PDs endorsed at least 50% of their residents participating in these activities.

Qualitative responses revealed that some PDs view CS as “a way for residents to stay connected to what drew them to medicine” and “essential to improving perceptions by physicians and patients about dermatology.” Program directors perceived lack of available time, initiative, and resources as well as minimal resident interest, malpractice coverage, and lack of educational opportunities as potential barriers to CS involvement by residents (Table). Forty-six (59.0%) PDs believed that CS should not be an ACGME requirement for dermatology training, 23 (29.5%) believed it should be required, and 9 (11.5%) were undecided.

Feedback From Residents—We received responses from 92 current dermatology residents and recent dermatology residency graduates; 86 (93.5%) respondents were trainees or recent graduates from academic dermatology residency training programs, and 6 (6.5%) were from community-based training programs. Community service was perceived to be an important part of dermatology training by 68 (73.9%) respondents, and dermatology-specific CS opportunities were available to 65 (70.7%) respondents (Figure 1). Although CS was required of only 7 (7.6%) respondents, 36 (39.1%) respondents volunteered at a free dermatology clinic during residency training. Among respondents who were not provided CS opportunities through their residency program, 23 (85.2%) stated they would have participated if given the opportunity.

Dermatology residents listed increased access to care for marginalized populations, increased sense of purpose, increased competence, and decreased burnout as perceived benefits of participation in CS. Of the dermatology residents who volunteered at a free dermatology clinic during training, 27 (75.0%) regarded the experience as a “high-yield learning opportunity.” Additionally, 29 (80.6%) residents stated their participation in a free dermatology clinic increased their awareness of health disparities and societal factors affecting dermatologic care in underserved patient populations. These respondents affirmed that their participation motivated them to become more involved in outreach targeting underserved populations throughout the duration of their careers.

Comment

The results of this nationwide survey have several important implications for dermatology residency programs, with a focus on programs in well-resourced and high socioeconomic status areas. Although most PDs believe that CS is important for dermatology resident training, few programs have CS requirements, and the majority are opposed to ACGME-mandated CS. Dermatology residents and recent graduates overwhelmingly conveyed that participation in a free dermatology clinic during residency training increased their knowledge base surrounding socioeconomic determinants of health and practicing in resource-limited settings. Furthermore, most trainees expressed that CS participation as a resident motivated them to continue to partake in CS for the underserved as an attending physician. The discordance between perceived value of CS by residents and the lack of CS requirements and opportunities by residency programs represents a realistic opportunity for residency training programs to integrate CS into the curriculum.

Residency programs that integrate service for the underserved into their program goals are 3 times more successful in graduating dermatology residents who practice in underserved communities.⁹ Patients in marginalized communities and those from lower socioeconomic backgrounds face many barriers to accessing dermatologic care including longer wait times and higher practice rejection rates than patients with private insurance.⁶ Through increased CS opportunities, dermatology residency programs can strengthen the local health care infrastructure and bridge the gap in access to dermatologic care.

By establishing a formal CS rotation in dermatology residency programs, residents will experience invaluable first-hand educational opportunities, provide comprehensive care for patients in resource-limited settings, and hopefully continue to serve in marginalized communities. Incorporating service for the underserved into the dermatology residency curriculum not only enhances the cultural competency of trainees but also mandates that skin health equity be made a priority. By exposing dermatology residents to the diverse patient populations often served by free clinics, residents will increase their knowledge of skin disease presentation in patients with darker skin tones, which has historically been deficient in medical education.^10,11

The limitations of this survey study included recall bias, the response rate of PDs (54.9%), and the inability to determine response rate of residents, as we were unable to establish the total number of residents who received our survey. Based on geographic location, some dermatology residency programs may treat a high percentage of medically underserved patients, which already improves access to dermatology. For this reason, follow-up studies correlating PD and resident responses with region, program size, and university/community affiliation will increase our understanding of CS participation and perceptions.

Conclusion

Dermatology residency program participation in CS helps reduce barriers to access for patients in marginalized communities. Incorporating CS into the dermatology residency program curriculum creates a rewarding training environment that increases skin health equity, fosters an interest in health disparities, and enhances the cultural competency of its trainees.

Community service (CS) or service learning in dermatology (eg, free skin cancer screenings, providing care through free clinics, free teledermatology consultations) is instrumental in mitigating disparities and improving access to equitable dermatologic care. With the rate of underinsured and uninsured patients on the rise, free and federally qualified clinics frequently are the sole means by which patients access specialty care such as dermatology.¹ Contributing to the economic gap in access, the geographic disparity of dermatologists in the United States continues to climb, and many marginalized communities remain without dermatologists.² Nearly 30% of the total US population resides in geographic areas that are underserved by dermatologists, while there appears to be an oversupply of dermatologists in urban areas.³ Dermatologists practicing in rural areas make up only 10% of the dermatology workforce,⁴ whereas 40% of all dermatologists practice in the most densely populated US cities.⁵ Consequently, patients in these underserved communities face longer wait times⁶ and are less likely to utilize dermatology services than patients in dermatologist-dense geographic areas.⁷

Service opportunities have become increasingly integrated into graduate medical education.⁸ These service activities help bridge the health care access gap while fulfilling Accreditation Council of Graduate Medical Education (ACGME) requirements. Our study assessed the importance of CS to dermatology residency program directors (PDs), dermatology residents, and recent dermatology residency graduates. Herein, we describe the perceptions of CS within dermatology residency training among PDs and residents.

Methods

In this study, CS is defined as participation in activities to increase dermatologic access, education, and resources to underserved communities. Using the approved Association of Professors of Dermatology listserve and direct email communication, we surveyed 142 PDs of ACGME-accredited dermatology residency training programs. The deidentified respondents voluntarily completed a 17-question Qualtrics survey with a 5-point Likert scale (extremely, very, moderately, slightly, or not at all), yes/no/undecided, and qualitative responses.

We also surveyed current dermatology residents and recent graduates of ACGME-accredited dermatology residency programs via PDs nationwide. The deidentified respondents voluntarily completed a 19-question Qualtrics survey with a 5-point Likert scale (extremely, very, moderately, slightly, or not at all), yes/no/undecided, and qualitative responses.

Descriptive statistics were used for data analysis for both Qualtrics surveys. The University of Pittsburgh institutional review board deemed this study exempt.

Results

Feedback From PDs—Of the 142 PDs, we received 78 responses (54.9%). For selection of dermatology residents, CS was moderately to extremely important to 64 (82.1%) PDs, and 63 (80.8%) PDs stated CS was moderately to extremely important to their dermatology residency program at large. For dermatology residency training, 66 (84.6%) PDs believed CS is important, whereas 3 (3.8%) believed it is not important, and 9 (11.5%) remained undecided (Figure 1). Notably, 17 (21.8%) programs required CS as part of the dermatology educational curriculum, with most of these programs requiring 10 hours or less during the 3 years of residency training. Of the programs with required CS, 15 (88.2%) had dermatology-specific CS requirements, with 10 (58.8%) programs involved in CS at free and/or underserved clinics and some programs participating in other CS activities, such as advocacy, mentorship, educational outreach, or sports (Figure 2A).

Community service opportunities were offered to dermatology residents by 69 (88.5%) programs, including the 17 programs that required CS as part of the dermatology educational curriculum. Among these programs with optional CS, 43 (82.7%) PDs reported CS opportunities at free and/or underserved clinics, and 30 (57.7%) reported CS opportunities through global health initiatives (Figure 2B). Other CS opportunities offered included partnerships with community outreach organizations and mentoring underprivileged students. Patient populations that benefit from CS offered by these dermatology residency programs included 55 (79.7%) underserved, 33 (47.8%) minority, 31 (44.9%) immigrant, 14 (20.3%) pediatric, 14 (20.3%) elderly, and 10 (14.5%) rural populations (Figure 2C). At dermatology residency programs with optional CS opportunities, 22 (42.3%) PDs endorsed at least 50% of their residents participating in these activities.

Qualitative responses revealed that some PDs view CS as “a way for residents to stay connected to what drew them to medicine” and “essential to improving perceptions by physicians and patients about dermatology.” Program directors perceived lack of available time, initiative, and resources as well as minimal resident interest, malpractice coverage, and lack of educational opportunities as potential barriers to CS involvement by residents (Table). Forty-six (59.0%) PDs believed that CS should not be an ACGME requirement for dermatology training, 23 (29.5%) believed it should be required, and 9 (11.5%) were undecided.

Feedback From Residents—We received responses from 92 current dermatology residents and recent dermatology residency graduates; 86 (93.5%) respondents were trainees or recent graduates from academic dermatology residency training programs, and 6 (6.5%) were from community-based training programs. Community service was perceived to be an important part of dermatology training by 68 (73.9%) respondents, and dermatology-specific CS opportunities were available to 65 (70.7%) respondents (Figure 1). Although CS was required of only 7 (7.6%) respondents, 36 (39.1%) respondents volunteered at a free dermatology clinic during residency training. Among respondents who were not provided CS opportunities through their residency program, 23 (85.2%) stated they would have participated if given the opportunity.

Dermatology residents listed increased access to care for marginalized populations, increased sense of purpose, increased competence, and decreased burnout as perceived benefits of participation in CS. Of the dermatology residents who volunteered at a free dermatology clinic during training, 27 (75.0%) regarded the experience as a “high-yield learning opportunity.” Additionally, 29 (80.6%) residents stated their participation in a free dermatology clinic increased their awareness of health disparities and societal factors affecting dermatologic care in underserved patient populations. These respondents affirmed that their participation motivated them to become more involved in outreach targeting underserved populations throughout the duration of their careers.

Comment

The results of this nationwide survey have several important implications for dermatology residency programs, with a focus on programs in well-resourced and high socioeconomic status areas. Although most PDs believe that CS is important for dermatology resident training, few programs have CS requirements, and the majority are opposed to ACGME-mandated CS. Dermatology residents and recent graduates overwhelmingly conveyed that participation in a free dermatology clinic during residency training increased their knowledge base surrounding socioeconomic determinants of health and practicing in resource-limited settings. Furthermore, most trainees expressed that CS participation as a resident motivated them to continue to partake in CS for the underserved as an attending physician. The discordance between perceived value of CS by residents and the lack of CS requirements and opportunities by residency programs represents a realistic opportunity for residency training programs to integrate CS into the curriculum.

Residency programs that integrate service for the underserved into their program goals are 3 times more successful in graduating dermatology residents who practice in underserved communities.⁹ Patients in marginalized communities and those from lower socioeconomic backgrounds face many barriers to accessing dermatologic care including longer wait times and higher practice rejection rates than patients with private insurance.⁶ Through increased CS opportunities, dermatology residency programs can strengthen the local health care infrastructure and bridge the gap in access to dermatologic care.

By establishing a formal CS rotation in dermatology residency programs, residents will experience invaluable first-hand educational opportunities, provide comprehensive care for patients in resource-limited settings, and hopefully continue to serve in marginalized communities. Incorporating service for the underserved into the dermatology residency curriculum not only enhances the cultural competency of trainees but also mandates that skin health equity be made a priority. By exposing dermatology residents to the diverse patient populations often served by free clinics, residents will increase their knowledge of skin disease presentation in patients with darker skin tones, which has historically been deficient in medical education.^10,11

The limitations of this survey study included recall bias, the response rate of PDs (54.9%), and the inability to determine response rate of residents, as we were unable to establish the total number of residents who received our survey. Based on geographic location, some dermatology residency programs may treat a high percentage of medically underserved patients, which already improves access to dermatology. For this reason, follow-up studies correlating PD and resident responses with region, program size, and university/community affiliation will increase our understanding of CS participation and perceptions.

Conclusion

Dermatology residency program participation in CS helps reduce barriers to access for patients in marginalized communities. Incorporating CS into the dermatology residency program curriculum creates a rewarding training environment that increases skin health equity, fosters an interest in health disparities, and enhances the cultural competency of its trainees.

Community service (CS) or service learning in dermatology (eg, free skin cancer screenings, providing care through free clinics, free teledermatology consultations) is instrumental in mitigating disparities and improving access to equitable dermatologic care. With the rate of underinsured and uninsured patients on the rise, free and federally qualified clinics frequently are the sole means by which patients access specialty care such as dermatology.¹ Contributing to the economic gap in access, the geographic disparity of dermatologists in the United States continues to climb, and many marginalized communities remain without dermatologists.² Nearly 30% of the total US population resides in geographic areas that are underserved by dermatologists, while there appears to be an oversupply of dermatologists in urban areas.³ Dermatologists practicing in rural areas make up only 10% of the dermatology workforce,⁴ whereas 40% of all dermatologists practice in the most densely populated US cities.⁵ Consequently, patients in these underserved communities face longer wait times⁶ and are less likely to utilize dermatology services than patients in dermatologist-dense geographic areas.⁷

Service opportunities have become increasingly integrated into graduate medical education.⁸ These service activities help bridge the health care access gap while fulfilling Accreditation Council of Graduate Medical Education (ACGME) requirements. Our study assessed the importance of CS to dermatology residency program directors (PDs), dermatology residents, and recent dermatology residency graduates. Herein, we describe the perceptions of CS within dermatology residency training among PDs and residents.

Methods

In this study, CS is defined as participation in activities to increase dermatologic access, education, and resources to underserved communities. Using the approved Association of Professors of Dermatology listserve and direct email communication, we surveyed 142 PDs of ACGME-accredited dermatology residency training programs. The deidentified respondents voluntarily completed a 17-question Qualtrics survey with a 5-point Likert scale (extremely, very, moderately, slightly, or not at all), yes/no/undecided, and qualitative responses.

We also surveyed current dermatology residents and recent graduates of ACGME-accredited dermatology residency programs via PDs nationwide. The deidentified respondents voluntarily completed a 19-question Qualtrics survey with a 5-point Likert scale (extremely, very, moderately, slightly, or not at all), yes/no/undecided, and qualitative responses.

Descriptive statistics were used for data analysis for both Qualtrics surveys. The University of Pittsburgh institutional review board deemed this study exempt.

Results

Feedback From PDs—Of the 142 PDs, we received 78 responses (54.9%). For selection of dermatology residents, CS was moderately to extremely important to 64 (82.1%) PDs, and 63 (80.8%) PDs stated CS was moderately to extremely important to their dermatology residency program at large. For dermatology residency training, 66 (84.6%) PDs believed CS is important, whereas 3 (3.8%) believed it is not important, and 9 (11.5%) remained undecided (Figure 1). Notably, 17 (21.8%) programs required CS as part of the dermatology educational curriculum, with most of these programs requiring 10 hours or less during the 3 years of residency training. Of the programs with required CS, 15 (88.2%) had dermatology-specific CS requirements, with 10 (58.8%) programs involved in CS at free and/or underserved clinics and some programs participating in other CS activities, such as advocacy, mentorship, educational outreach, or sports (Figure 2A).

Community service opportunities were offered to dermatology residents by 69 (88.5%) programs, including the 17 programs that required CS as part of the dermatology educational curriculum. Among these programs with optional CS, 43 (82.7%) PDs reported CS opportunities at free and/or underserved clinics, and 30 (57.7%) reported CS opportunities through global health initiatives (Figure 2B). Other CS opportunities offered included partnerships with community outreach organizations and mentoring underprivileged students. Patient populations that benefit from CS offered by these dermatology residency programs included 55 (79.7%) underserved, 33 (47.8%) minority, 31 (44.9%) immigrant, 14 (20.3%) pediatric, 14 (20.3%) elderly, and 10 (14.5%) rural populations (Figure 2C). At dermatology residency programs with optional CS opportunities, 22 (42.3%) PDs endorsed at least 50% of their residents participating in these activities.

Qualitative responses revealed that some PDs view CS as “a way for residents to stay connected to what drew them to medicine” and “essential to improving perceptions by physicians and patients about dermatology.” Program directors perceived lack of available time, initiative, and resources as well as minimal resident interest, malpractice coverage, and lack of educational opportunities as potential barriers to CS involvement by residents (Table). Forty-six (59.0%) PDs believed that CS should not be an ACGME requirement for dermatology training, 23 (29.5%) believed it should be required, and 9 (11.5%) were undecided.

Feedback From Residents—We received responses from 92 current dermatology residents and recent dermatology residency graduates; 86 (93.5%) respondents were trainees or recent graduates from academic dermatology residency training programs, and 6 (6.5%) were from community-based training programs. Community service was perceived to be an important part of dermatology training by 68 (73.9%) respondents, and dermatology-specific CS opportunities were available to 65 (70.7%) respondents (Figure 1). Although CS was required of only 7 (7.6%) respondents, 36 (39.1%) respondents volunteered at a free dermatology clinic during residency training. Among respondents who were not provided CS opportunities through their residency program, 23 (85.2%) stated they would have participated if given the opportunity.

Dermatology residents listed increased access to care for marginalized populations, increased sense of purpose, increased competence, and decreased burnout as perceived benefits of participation in CS. Of the dermatology residents who volunteered at a free dermatology clinic during training, 27 (75.0%) regarded the experience as a “high-yield learning opportunity.” Additionally, 29 (80.6%) residents stated their participation in a free dermatology clinic increased their awareness of health disparities and societal factors affecting dermatologic care in underserved patient populations. These respondents affirmed that their participation motivated them to become more involved in outreach targeting underserved populations throughout the duration of their careers.

Comment

The results of this nationwide survey have several important implications for dermatology residency programs, with a focus on programs in well-resourced and high socioeconomic status areas. Although most PDs believe that CS is important for dermatology resident training, few programs have CS requirements, and the majority are opposed to ACGME-mandated CS. Dermatology residents and recent graduates overwhelmingly conveyed that participation in a free dermatology clinic during residency training increased their knowledge base surrounding socioeconomic determinants of health and practicing in resource-limited settings. Furthermore, most trainees expressed that CS participation as a resident motivated them to continue to partake in CS for the underserved as an attending physician. The discordance between perceived value of CS by residents and the lack of CS requirements and opportunities by residency programs represents a realistic opportunity for residency training programs to integrate CS into the curriculum.

Residency programs that integrate service for the underserved into their program goals are 3 times more successful in graduating dermatology residents who practice in underserved communities.⁹ Patients in marginalized communities and those from lower socioeconomic backgrounds face many barriers to accessing dermatologic care including longer wait times and higher practice rejection rates than patients with private insurance.⁶ Through increased CS opportunities, dermatology residency programs can strengthen the local health care infrastructure and bridge the gap in access to dermatologic care.

By establishing a formal CS rotation in dermatology residency programs, residents will experience invaluable first-hand educational opportunities, provide comprehensive care for patients in resource-limited settings, and hopefully continue to serve in marginalized communities. Incorporating service for the underserved into the dermatology residency curriculum not only enhances the cultural competency of trainees but also mandates that skin health equity be made a priority. By exposing dermatology residents to the diverse patient populations often served by free clinics, residents will increase their knowledge of skin disease presentation in patients with darker skin tones, which has historically been deficient in medical education.^10,11

The limitations of this survey study included recall bias, the response rate of PDs (54.9%), and the inability to determine response rate of residents, as we were unable to establish the total number of residents who received our survey. Based on geographic location, some dermatology residency programs may treat a high percentage of medically underserved patients, which already improves access to dermatology. For this reason, follow-up studies correlating PD and resident responses with region, program size, and university/community affiliation will increase our understanding of CS participation and perceptions.

Conclusion

Dermatology residency program participation in CS helps reduce barriers to access for patients in marginalized communities. Incorporating CS into the dermatology residency program curriculum creates a rewarding training environment that increases skin health equity, fosters an interest in health disparities, and enhances the cultural competency of its trainees.

As residents, it is important to understand the steps of the manicuring process and be able to inform patients on how to maintain optimal nail health while continuing to go to nail salons. Most patients are not aware of the possible allergic, traumatic, and/or infectious complications of manicuring their nails. There are practical steps that can be taken to prevent nail issues, such as avoiding cutting one’s cuticles or using allergen-free nail polishes. These simple fixes can make a big difference in long-term nail health in our patients.

Nail Polish Application Process

The nails are first soaked in a warm soapy solution to soften the nail plate and cuticles.¹ Then the nail tips and plates are filed and occasionally are smoothed with a drill. The cuticles are cut with a cuticle cutter. Nail polish—base coat, color enamel, and top coat—is then applied to the nail. Acrylic or sculptured nails and gel and dip manicures are composed of chemical monomers and polymers that harden either at room temperature or through UV or light-emitting diode (LED) exposure. The chemicals in these products can damage nails and cause allergic reactions.

Contact Dermatitis

Approximately 2% of individuals have been found to have allergic or irritant contact dermatitis to nail care products. The top 5 allergens implicated in nail products are (1) 2-hydroxyethyl methacrylate, (2) methyl methacrylate, (3) ethyl acrylate, (4) ethyl-2-cyanoacrylate, and (5) tosylamide.² Methyl methacrylate was banned in 1974 by the US Food and Drug Administration due to reports of severe contact dermatitis, paronychia, and nail dystrophy.³ Due to their potent sensitizing effects, acrylates were named the contact allergen of the year in 2012 by the American Contact Dermatitis Society.³

Acrylates are plastic products formed by polymerization of acrylic or methacrylic acid.⁴ Artificial sculptured nails are created by mixing powdered polymethyl methacrylate polymers and liquid ethyl or isobutyl methacrylate monomers and then applying this mixture to the nail plate.⁵ Gel and powder nails employ a mixture that is similar to acrylic powders, which require UV or LED radiation to polymerize and harden on the nail plate.

Tosylamide, or tosylamide formaldehyde resin, is another potent allergen that promotes adhesion of the enamel to the nail.⁶ It is important to note that sensitization may develop months to years after using artificial nails.

Clinical features of contact allergy secondary to nail polish can vary. Some patients experience severe periungual dermatitis. Others can present with facial or eyelid dermatitis due to exposure to airborne particles of acrylates or from contact with fingertips bearing acrylic nails.^6,7 If inhaled, acrylates also can cause wheezing asthma or allergic rhinoconjunctivitis.

Common Onychodystrophies

Damage to the natural nail plate is inevitable with continued wear of sculptured nails. With 2 to 4 months of consecutive wear, the natural nails turn yellow, brittle, and weak.⁵ One study noted that the thickness of an individual’s left thumb nail plate thinned from 0.059 cm to 0.03 cm after a gel manicure was removed from the nail.⁸ Nail injuries due to manicuring include keratin granulations, onycholysis, pincer nail deformities, pseudopsoriatic nails, lamellar onychoschizia, transverse leukonychia, and ingrown nails.⁶ One interesting nail dystrophy reported secondary to gel manicures is pterygium inversum unguis or a ventral pterygium that causes an abnormal painful adherence of the hyponychium to the ventral surface of the nail plate. Patients prone to developing pterygium inversum unguis can experience sensitivity, pain, or burning sensations during LED or UVA light exposure.⁹

Infections

In addition to contact allergies and nail dystrophies, each step of the manicuring process, such as cutting cuticles, presents opportunities for infectious agents to enter the nail fold. Acute or chronic paronychia, or inflammation of the nail fold, most commonly is caused by bacterial infections with Staphylococcus aureus. Green nail syndrome caused by Pseudomonas aeruginosa also is common.¹ Onychomycosis due to Trichophyton rubrum is one of the most frequent fungal infections contracted at nail salons. Mycobacteria such as Mycobacterium fortuitum also have been implicated in infections from salons, as they can be found in the jets of pedicure spas, which are not sanitized regularly.¹⁰

Final Thoughts

Nail cosmetics are an integral part of many patients’ lives. Being able to educate yourself and your patients on the hazards of nail salons can help them avoid painful infections, contact allergies, and acute to chronic nail deformities. It is important for residents to be aware of the different dermatoses that can arise in men and women who frequent nail salons as the popularity of the nail beauty industry continues to rise.

As residents, it is important to understand the steps of the manicuring process and be able to inform patients on how to maintain optimal nail health while continuing to go to nail salons. Most patients are not aware of the possible allergic, traumatic, and/or infectious complications of manicuring their nails. There are practical steps that can be taken to prevent nail issues, such as avoiding cutting one’s cuticles or using allergen-free nail polishes. These simple fixes can make a big difference in long-term nail health in our patients.

Nail Polish Application Process

The nails are first soaked in a warm soapy solution to soften the nail plate and cuticles.¹ Then the nail tips and plates are filed and occasionally are smoothed with a drill. The cuticles are cut with a cuticle cutter. Nail polish—base coat, color enamel, and top coat—is then applied to the nail. Acrylic or sculptured nails and gel and dip manicures are composed of chemical monomers and polymers that harden either at room temperature or through UV or light-emitting diode (LED) exposure. The chemicals in these products can damage nails and cause allergic reactions.

Contact Dermatitis

Approximately 2% of individuals have been found to have allergic or irritant contact dermatitis to nail care products. The top 5 allergens implicated in nail products are (1) 2-hydroxyethyl methacrylate, (2) methyl methacrylate, (3) ethyl acrylate, (4) ethyl-2-cyanoacrylate, and (5) tosylamide.² Methyl methacrylate was banned in 1974 by the US Food and Drug Administration due to reports of severe contact dermatitis, paronychia, and nail dystrophy.³ Due to their potent sensitizing effects, acrylates were named the contact allergen of the year in 2012 by the American Contact Dermatitis Society.³

Acrylates are plastic products formed by polymerization of acrylic or methacrylic acid.⁴ Artificial sculptured nails are created by mixing powdered polymethyl methacrylate polymers and liquid ethyl or isobutyl methacrylate monomers and then applying this mixture to the nail plate.⁵ Gel and powder nails employ a mixture that is similar to acrylic powders, which require UV or LED radiation to polymerize and harden on the nail plate.

Tosylamide, or tosylamide formaldehyde resin, is another potent allergen that promotes adhesion of the enamel to the nail.⁶ It is important to note that sensitization may develop months to years after using artificial nails.

Clinical features of contact allergy secondary to nail polish can vary. Some patients experience severe periungual dermatitis. Others can present with facial or eyelid dermatitis due to exposure to airborne particles of acrylates or from contact with fingertips bearing acrylic nails.^6,7 If inhaled, acrylates also can cause wheezing asthma or allergic rhinoconjunctivitis.

Common Onychodystrophies

Damage to the natural nail plate is inevitable with continued wear of sculptured nails. With 2 to 4 months of consecutive wear, the natural nails turn yellow, brittle, and weak.⁵ One study noted that the thickness of an individual’s left thumb nail plate thinned from 0.059 cm to 0.03 cm after a gel manicure was removed from the nail.⁸ Nail injuries due to manicuring include keratin granulations, onycholysis, pincer nail deformities, pseudopsoriatic nails, lamellar onychoschizia, transverse leukonychia, and ingrown nails.⁶ One interesting nail dystrophy reported secondary to gel manicures is pterygium inversum unguis or a ventral pterygium that causes an abnormal painful adherence of the hyponychium to the ventral surface of the nail plate. Patients prone to developing pterygium inversum unguis can experience sensitivity, pain, or burning sensations during LED or UVA light exposure.⁹

Infections

In addition to contact allergies and nail dystrophies, each step of the manicuring process, such as cutting cuticles, presents opportunities for infectious agents to enter the nail fold. Acute or chronic paronychia, or inflammation of the nail fold, most commonly is caused by bacterial infections with Staphylococcus aureus. Green nail syndrome caused by Pseudomonas aeruginosa also is common.¹ Onychomycosis due to Trichophyton rubrum is one of the most frequent fungal infections contracted at nail salons. Mycobacteria such as Mycobacterium fortuitum also have been implicated in infections from salons, as they can be found in the jets of pedicure spas, which are not sanitized regularly.¹⁰

Final Thoughts

Nail cosmetics are an integral part of many patients’ lives. Being able to educate yourself and your patients on the hazards of nail salons can help them avoid painful infections, contact allergies, and acute to chronic nail deformities. It is important for residents to be aware of the different dermatoses that can arise in men and women who frequent nail salons as the popularity of the nail beauty industry continues to rise.

As residents, it is important to understand the steps of the manicuring process and be able to inform patients on how to maintain optimal nail health while continuing to go to nail salons. Most patients are not aware of the possible allergic, traumatic, and/or infectious complications of manicuring their nails. There are practical steps that can be taken to prevent nail issues, such as avoiding cutting one’s cuticles or using allergen-free nail polishes. These simple fixes can make a big difference in long-term nail health in our patients.

Nail Polish Application Process

The nails are first soaked in a warm soapy solution to soften the nail plate and cuticles.¹ Then the nail tips and plates are filed and occasionally are smoothed with a drill. The cuticles are cut with a cuticle cutter. Nail polish—base coat, color enamel, and top coat—is then applied to the nail. Acrylic or sculptured nails and gel and dip manicures are composed of chemical monomers and polymers that harden either at room temperature or through UV or light-emitting diode (LED) exposure. The chemicals in these products can damage nails and cause allergic reactions.

Contact Dermatitis

Approximately 2% of individuals have been found to have allergic or irritant contact dermatitis to nail care products. The top 5 allergens implicated in nail products are (1) 2-hydroxyethyl methacrylate, (2) methyl methacrylate, (3) ethyl acrylate, (4) ethyl-2-cyanoacrylate, and (5) tosylamide.² Methyl methacrylate was banned in 1974 by the US Food and Drug Administration due to reports of severe contact dermatitis, paronychia, and nail dystrophy.³ Due to their potent sensitizing effects, acrylates were named the contact allergen of the year in 2012 by the American Contact Dermatitis Society.³

Acrylates are plastic products formed by polymerization of acrylic or methacrylic acid.⁴ Artificial sculptured nails are created by mixing powdered polymethyl methacrylate polymers and liquid ethyl or isobutyl methacrylate monomers and then applying this mixture to the nail plate.⁵ Gel and powder nails employ a mixture that is similar to acrylic powders, which require UV or LED radiation to polymerize and harden on the nail plate.

Tosylamide, or tosylamide formaldehyde resin, is another potent allergen that promotes adhesion of the enamel to the nail.⁶ It is important to note that sensitization may develop months to years after using artificial nails.

Clinical features of contact allergy secondary to nail polish can vary. Some patients experience severe periungual dermatitis. Others can present with facial or eyelid dermatitis due to exposure to airborne particles of acrylates or from contact with fingertips bearing acrylic nails.^6,7 If inhaled, acrylates also can cause wheezing asthma or allergic rhinoconjunctivitis.

Common Onychodystrophies

Damage to the natural nail plate is inevitable with continued wear of sculptured nails. With 2 to 4 months of consecutive wear, the natural nails turn yellow, brittle, and weak.⁵ One study noted that the thickness of an individual’s left thumb nail plate thinned from 0.059 cm to 0.03 cm after a gel manicure was removed from the nail.⁸ Nail injuries due to manicuring include keratin granulations, onycholysis, pincer nail deformities, pseudopsoriatic nails, lamellar onychoschizia, transverse leukonychia, and ingrown nails.⁶ One interesting nail dystrophy reported secondary to gel manicures is pterygium inversum unguis or a ventral pterygium that causes an abnormal painful adherence of the hyponychium to the ventral surface of the nail plate. Patients prone to developing pterygium inversum unguis can experience sensitivity, pain, or burning sensations during LED or UVA light exposure.⁹

Infections

In addition to contact allergies and nail dystrophies, each step of the manicuring process, such as cutting cuticles, presents opportunities for infectious agents to enter the nail fold. Acute or chronic paronychia, or inflammation of the nail fold, most commonly is caused by bacterial infections with Staphylococcus aureus. Green nail syndrome caused by Pseudomonas aeruginosa also is common.¹ Onychomycosis due to Trichophyton rubrum is one of the most frequent fungal infections contracted at nail salons. Mycobacteria such as Mycobacterium fortuitum also have been implicated in infections from salons, as they can be found in the jets of pedicure spas, which are not sanitized regularly.¹⁰

Final Thoughts

Nail cosmetics are an integral part of many patients’ lives. Being able to educate yourself and your patients on the hazards of nail salons can help them avoid painful infections, contact allergies, and acute to chronic nail deformities. It is important for residents to be aware of the different dermatoses that can arise in men and women who frequent nail salons as the popularity of the nail beauty industry continues to rise.

ABSTRACT

Background: Medical assistant (MA) roles have expanded rapidly as primary care has evolved and MAs take on new patient care duties. Research that looks at the MA experience and factors that enhance or reduce efficiency among MAs is limited.

Methods: We surveyed all MAs working in 6 clinics run by a large academic family medicine department in Ann Arbor, Michigan. MAs deemed by peers as “most efficient” were selected for follow-up interviews. We evaluated personal strategies for efficiency, barriers to efficient care, impact of physician actions on efficiency, and satisfaction.

Results: A total of 75/86 MAs (87%) responded to at least some survey questions and 61/86 (71%) completed the full survey. We interviewed 18 MAs face to face. Most saw their role as essential to clinic functioning and viewed health care as a personal calling. MAs identified common strategies to improve efficiency and described the MA role to orchestrate the flow of the clinic day. Staff recognized differing priorities of patients, staff, and physicians and articulated frustrations with hierarchy and competing priorities as well as behaviors that impeded clinic efficiency. Respondents emphasized the importance of feeling valued by others on their team.

Conclusions: With the evolving demands made on MAs’ time, it is critical to understand how the most effective staff members manage their role and highlight the strategies they employ to provide efficient clinical care. Understanding factors that increase or decrease MA job satisfaction can help identify high-efficiency practices and promote a clinic culture that values and supports all staff.

As primary care continues to evolve into more team-based practice, the role of the medical assistant (MA) has rapidly transformed.¹ Staff may assist with patient management, documentation in the electronic medical record, order entry, pre-visit planning, and fulfillment of quality metrics, particularly in a Primary Care Medical Home (PCMH).² From 2012 through 2014, MA job postings per graduate increased from 1.3 to 2.3, suggesting twice as many job postings as graduates.³ As the demand for experienced MAs increases, the ability to recruit and retain high-performing staff members will be critical.

MAs are referenced in medical literature as early as the 1800s.⁴ The American Association of Medical Assistants was founded in 1956, which led to educational standardization and certifications.⁵ Despite the important role that MAs have long played in the proper functioning of a medical clinic—and the knowledge that team configurations impact a clinic’s efficiency and quality^6,7—few investigations have sought out the MA’s perspective.^8,9 Given the increasing clinical demands placed on all members of the primary care team (and the burnout that often results), it seems that MA insights into clinic efficiency could be valuable.

Continue to: Methods...

METHODS

This cross-sectional study was conducted from February to April 2019 at a large academic institution with 6 regional ambulatory care family medicine clinics, each one with 11,000 to 18,000 patient visits annually. Faculty work at all 6 clinics and residents at 2 of them. All MAs are hired, paid, and managed by a central administrative department rather than by the family medicine department. The family medicine clinics are currently PCMH certified, with a mix of fee-for-service and capitated reimbursement.

We developed and piloted a voluntary, anonymous 39-question (29 closed-ended and 10 brief open-ended) online Qualtrics survey, which we distributed via an email link to all the MAs in the department. The survey included clinic site, years as an MA, perceptions of the clinic environment, perception of teamwork at their site, identification of efficient practices, and feedback for physicians to improve efficiency and flow. Most questions were Likert-style with 5 choices ranging from “strongly agree” to “strongly disagree” or short answer. Age and gender were omitted to protect confidentiality, as most MAs in the department are female. Participants could opt to enter in a drawing for three $25 gift cards. The survey was reviewed by the University of Michigan Institutional Review Board and deemed exempt.
 

Seventy-five percent of MAs reported preclinic huddles to plan for patient care were helpful, but only half said huddles took place “always” or “most of the time.”

We asked MAs to nominate peers in their clinic who were “especially efficient and do their jobs well—people that others can learn from.” The staff members who were nominated most frequently by their peers were invited to share additional perspectives via a 10- to 30-minute semi-structured interview with the first author. Interviews covered highly efficient practices, barriers and facilitators to efficient care, and physician behaviors that impaired efficiency. We interviewed a minimum of 2 MAs per clinic and increased the number of interviews through snowball sampling, as needed, to reach data saturation (eg, the point at which we were no longer hearing new content). MAs were assured that all comments would be anonymized. There was no monetary incentive for the interviews. The interviewer had previously met only 3 of the 18 MAs interviewed.

Analysis. Summary statistics were calculated for quantitative data. To compare subgroups (such as individual clinics), a chi-square test was used. In cases when there were small cell sizes (< 5 subjects), we used the Fisher’s Exact test. Qualitative data was collected with real-time typewritten notes during the interviews to capture ideas and verbatim quotes when possible. We also included open-ended comments shared on the Qualtrics survey. Data were organized by theme using a deductive coding approach. Both authors reviewed and discussed observations, and coding was conducted by the first author. Reporting followed the STROBE Statement checklist for cross-sectional studies.¹⁰ Results were shared with MAs, supervisory staff, and physicians, which allowed for feedback and comments and served as “member-checking.” MAs reported that the data reflected their lived experiences.

Continue to: RESULTS...

RESULTS

Surveys were distributed to all 86 MAs working in family medicine clinics. A total of 75 (87%) responded to at least some questions (typically just demographics). We used those who completed the full survey (n = 61; 71%) for data analysis. Eighteen MAs participated in face-to-face interviews. Among respondents, 35 (47%) had worked at least 10 years as an MA and 21 (28%) had worked at least a decade in the family medicine department.

Perception of role

All respondents (n = 61; 100%) somewhat or strongly agreed that the MA role was “very important to keep the clinic functioning” and 58 (95%) reported that working in health care was “a calling” for them. Only 7 (11%) agreed that family medicine was an easier environment for MAs compared to a specialty clinic; 30 (49%) disagreed with this. Among respondents, 32 (53%) strongly or somewhat agreed that their work was very stressful and just half (n = 28; 46%) agreed there were adequate MA staff at their clinic.

Efficiency and competing priorities

MAs described important work values that increased their efficiency. These included clinic culture (good communication and strong teamwork), as well as individual strategies such as multitasking, limiting patient conversations, and doing tasks in a consistent way to improve accuracy. (See TABLE 1.) They identified ways physicians bolster or hurt efficiency and ways in which the relationship between the physician and the MA shapes the MA’s perception of their value in clinic.

When asked about “pet peeves,” a few MAs advised that physicians should not “talk down” to staff and should try to teach rather than criticize.

Communication was emphasized as critical for efficient care, and MAs encouraged the use of preclinic huddles and communication as priorities. Seventy-five percent of MAs reported preclinic huddles to plan for patient care were helpful, but only half said huddles took place “always” or “most of the time.” Many described reviewing the schedule and completing tasks ahead of patient arrival as critical to efficiency.

Participants described the tension between their identified role of orchestrating clinic flow and responding to directives by others that disrupted the flow. Several MAs found it challenging when physicians agreed to see very late patients and felt frustrated when decisions that changed the flow were made by the physician or front desk staff without including the MA. MAs were also able to articulate how they managed competing priorities within the clinic, such as when a patient- or physician-driven need to extend appointments was at odds with maintaining a timely schedule. They were eager to share personal tips for time management and prided themselves on careful and accurate performance and skills they had learned on the job. MAs also described how efficiency could be adversely affected by the behaviors or attitudes of physicians. (See TABLE 2.)

Continue to: Clinic environment...

Clinic environment

Thirty-six MAs (59%) reported that other MAs on their team were willing to help them out in clinic “a great deal” or “a lot” of the time, by helping to room a patient, acting as a chaperone for an exam, or doing a point-of-care lab. This sense of support varied across clinics (38% to 91% reported good support), suggesting that cultures vary by site. Some MAs expressed frustration at peers they saw as resistant to helping, exemplified by this verbatim quote from an interview:

“Some don’t want to help out. They may sigh. It’s how they react—you just know.” (Clinic #1, MA #2 interview)

Efficient MAs stressed the need for situational awareness to recognize when co-workers need help:

“[Peers often] are not aware that another MA is drowning. There’s 5 people who could have done that, and here I am running around and nobody budged.” (Clinic #5, MA #2 interview)

A minority of staff used the open-ended survey sections to describe clinic hierarchy. When asked about “pet peeves,” a few advised that physicians should not “talk down” to staff and should try to teach rather than criticize. Another asked that physicians not “bark orders” or have “low gratitude” for staff work. MAs found micromanaging stressful—particularly when the physician prompted the MA about patient arrivals:

“[I don’t like] when providers will make a comment about a patient arriving when you already know this information. You then rush to put [the] patient in [a] room, then [the] provider ends up making [the] patient wait an extensive amount of time. I’m perfectly capable of knowing when a patient arrives.” (Clinic #6, survey)
 

MAs did not like physicians “talking bad about us” or blaming the MA if the clinic is running behind.
 

Despite these concerns, most MAs reported feeling appreciated for the job they do. Only 10 (16%) reported that the people they work with rarely say “thank you,” and 2 (3%) stated they were not well supported by the physicians in clinic. Most (n = 38; 62%) strongly agreed or agreed that they felt part of the team and that their opinions matter. In the interviews, many expanded on this idea:

“I really feel like I’m valued, so I want to do everything I can to make [my doctor’s] day go better. If you want a good clinic, the best thing a doc can do is make the MA feel valued.” (Clinic #1, MA #1 interview)

Continue to: DISCUSSION...

DISCUSSION

Participants described their role much as an orchestra director, with MAs as the key to clinic flow and timeliness.⁹ Respondents articulated multiple common strategies used to increase their own efficiency and clinic flow; these may be considered best practices and incorporated as part of the basic training. Most MAs reported their day-to-day jobs were stressful and believed this was underrecognized, so efficiency strategies are critical. With staff completing multiple time-sensitive tasks during clinic, consistent co-worker support is crucial and may impact efficiency.⁸ Proper training of managers to provide that support and ensure equitable workloads may be one strategy to ensure that staff members feel the workplace is fair and collegial.

Several comments reflected the power differential within medical offices. One study reported that MAs and physicians “occupy roles at opposite ends of social and occupational hierarchies.”¹¹ It’s important for physicians to be cognizant of these patterns and clinic culture, as reducing a hierarchy-based environment will be appreciated by MAs.⁹ Prior research has found that MAs have higher perceptions of their own competence than do the physicians working with them.¹² If there is a fundamental lack of trust between the 2 groups, this will undoubtedly hinder team-building. Attention to this issue is key to a more favorable work environment.

Almost all respondents reported health care was a “calling,” which mirrors physician research that suggests seeing work as a “calling” is protective against burnout.^13,14 Open-ended comments indicated great pride in contributions, and most staff members felt appreciated by their teams. Many described the working relationships with physicians as critical to their satisfaction at work and indicated that strong partnerships motivated them to do their best to make the physician’s day easier. Staff job satisfaction is linked to improved quality of care, so treating staff well contributes to high-value care for patients.¹⁵ We also uncovered some MA “pet peeves” that hinder efficiency and could be shared with physicians to emphasize the importance of patience and civility.

One barrier to expansion of MA roles within PCMH practices is the limited pay and career ladder for MAs who adopt new job responsibilities that require advanced skills or training.^1,2 The mean MA salary at our institution ($37,372) is higher than in our state overall ($33,760), which may impact satisfaction.¹⁶ In addition, 93% of MAs are women; thus, they may continue to struggle more with lower pay than do workers in male- dominated professions.^17,18 Expected job growth from 2018-2028 is predicted at 23%, which may help to boost salaries. ¹⁹  Prior studies describe the lack of a job ladder or promotion opportunities as a challenge^1,20; this was not formally assessed in our study.


Prior research has found that MAs have higher perceptions of their own competence than do the physicians working with them.

MAs see work in family medicine as much harder than it is in other   specialty clinics. Being trusted with more responsibility, greater autonomy,^21-23 and expanded patient care roles can boost MA self-efficacy, which can reduce burnout for both physicians and MAs. ^8,24  However, new responsibilities should include appropriate training, support, and compensation, and match staff interests.⁷

Study limitations. The study was limited to 6 clinics in 1 department at a large academic medical center. Interviewed participants were selected by convenience and snowball sampling and thus, the results cannot be generalized to the population of MAs as a whole. As the initial interview goal was simply to gather efficiency tips, the project was not designed to be formal qualitative research. However, the discussions built on open-ended comments from the written survey helped contextualize our quantitative findings about efficiency. Notes were documented in real time by a single interviewer with rapid typing skills, which allowed capture of quotes verbatim. Subsequent studies would benefit from more formal qualitative research methods (recording and transcribing interviews, multiple coders to reduce risk of bias, and more complex thematic analysis).

Our research demonstrated how MAs perceive their roles in primary care and the facilitators and barriers to high efficiency in the workplace, which begins to fill an important knowledge gap in primary care. Disseminating practices that staff members themselves have identified as effective, and being attentive to how staff members are treated, may increase individual efficiency while improving staff retention and satisfaction.

CORRESPONDENCE Katherine J. Gold, MD, MSW, MS, Department of Family Medicine and Department of Obstetrics and Gynecology, University of Michigan, 1018 Fuller Street, Ann Arbor, MI 48104-1213; [email protected]

ABSTRACT

Background: Medical assistant (MA) roles have expanded rapidly as primary care has evolved and MAs take on new patient care duties. Research that looks at the MA experience and factors that enhance or reduce efficiency among MAs is limited.

Methods: We surveyed all MAs working in 6 clinics run by a large academic family medicine department in Ann Arbor, Michigan. MAs deemed by peers as “most efficient” were selected for follow-up interviews. We evaluated personal strategies for efficiency, barriers to efficient care, impact of physician actions on efficiency, and satisfaction.

Results: A total of 75/86 MAs (87%) responded to at least some survey questions and 61/86 (71%) completed the full survey. We interviewed 18 MAs face to face. Most saw their role as essential to clinic functioning and viewed health care as a personal calling. MAs identified common strategies to improve efficiency and described the MA role to orchestrate the flow of the clinic day. Staff recognized differing priorities of patients, staff, and physicians and articulated frustrations with hierarchy and competing priorities as well as behaviors that impeded clinic efficiency. Respondents emphasized the importance of feeling valued by others on their team.

Conclusions: With the evolving demands made on MAs’ time, it is critical to understand how the most effective staff members manage their role and highlight the strategies they employ to provide efficient clinical care. Understanding factors that increase or decrease MA job satisfaction can help identify high-efficiency practices and promote a clinic culture that values and supports all staff.

As primary care continues to evolve into more team-based practice, the role of the medical assistant (MA) has rapidly transformed.¹ Staff may assist with patient management, documentation in the electronic medical record, order entry, pre-visit planning, and fulfillment of quality metrics, particularly in a Primary Care Medical Home (PCMH).² From 2012 through 2014, MA job postings per graduate increased from 1.3 to 2.3, suggesting twice as many job postings as graduates.³ As the demand for experienced MAs increases, the ability to recruit and retain high-performing staff members will be critical.

MAs are referenced in medical literature as early as the 1800s.⁴ The American Association of Medical Assistants was founded in 1956, which led to educational standardization and certifications.⁵ Despite the important role that MAs have long played in the proper functioning of a medical clinic—and the knowledge that team configurations impact a clinic’s efficiency and quality^6,7—few investigations have sought out the MA’s perspective.^8,9 Given the increasing clinical demands placed on all members of the primary care team (and the burnout that often results), it seems that MA insights into clinic efficiency could be valuable.

Continue to: Methods...

METHODS

This cross-sectional study was conducted from February to April 2019 at a large academic institution with 6 regional ambulatory care family medicine clinics, each one with 11,000 to 18,000 patient visits annually. Faculty work at all 6 clinics and residents at 2 of them. All MAs are hired, paid, and managed by a central administrative department rather than by the family medicine department. The family medicine clinics are currently PCMH certified, with a mix of fee-for-service and capitated reimbursement.

We developed and piloted a voluntary, anonymous 39-question (29 closed-ended and 10 brief open-ended) online Qualtrics survey, which we distributed via an email link to all the MAs in the department. The survey included clinic site, years as an MA, perceptions of the clinic environment, perception of teamwork at their site, identification of efficient practices, and feedback for physicians to improve efficiency and flow. Most questions were Likert-style with 5 choices ranging from “strongly agree” to “strongly disagree” or short answer. Age and gender were omitted to protect confidentiality, as most MAs in the department are female. Participants could opt to enter in a drawing for three $25 gift cards. The survey was reviewed by the University of Michigan Institutional Review Board and deemed exempt.
 

Seventy-five percent of MAs reported preclinic huddles to plan for patient care were helpful, but only half said huddles took place “always” or “most of the time.”

We asked MAs to nominate peers in their clinic who were “especially efficient and do their jobs well—people that others can learn from.” The staff members who were nominated most frequently by their peers were invited to share additional perspectives via a 10- to 30-minute semi-structured interview with the first author. Interviews covered highly efficient practices, barriers and facilitators to efficient care, and physician behaviors that impaired efficiency. We interviewed a minimum of 2 MAs per clinic and increased the number of interviews through snowball sampling, as needed, to reach data saturation (eg, the point at which we were no longer hearing new content). MAs were assured that all comments would be anonymized. There was no monetary incentive for the interviews. The interviewer had previously met only 3 of the 18 MAs interviewed.

Analysis. Summary statistics were calculated for quantitative data. To compare subgroups (such as individual clinics), a chi-square test was used. In cases when there were small cell sizes (< 5 subjects), we used the Fisher’s Exact test. Qualitative data was collected with real-time typewritten notes during the interviews to capture ideas and verbatim quotes when possible. We also included open-ended comments shared on the Qualtrics survey. Data were organized by theme using a deductive coding approach. Both authors reviewed and discussed observations, and coding was conducted by the first author. Reporting followed the STROBE Statement checklist for cross-sectional studies.¹⁰ Results were shared with MAs, supervisory staff, and physicians, which allowed for feedback and comments and served as “member-checking.” MAs reported that the data reflected their lived experiences.

Continue to: RESULTS...

RESULTS

Surveys were distributed to all 86 MAs working in family medicine clinics. A total of 75 (87%) responded to at least some questions (typically just demographics). We used those who completed the full survey (n = 61; 71%) for data analysis. Eighteen MAs participated in face-to-face interviews. Among respondents, 35 (47%) had worked at least 10 years as an MA and 21 (28%) had worked at least a decade in the family medicine department.

Perception of role

All respondents (n = 61; 100%) somewhat or strongly agreed that the MA role was “very important to keep the clinic functioning” and 58 (95%) reported that working in health care was “a calling” for them. Only 7 (11%) agreed that family medicine was an easier environment for MAs compared to a specialty clinic; 30 (49%) disagreed with this. Among respondents, 32 (53%) strongly or somewhat agreed that their work was very stressful and just half (n = 28; 46%) agreed there were adequate MA staff at their clinic.

Efficiency and competing priorities

MAs described important work values that increased their efficiency. These included clinic culture (good communication and strong teamwork), as well as individual strategies such as multitasking, limiting patient conversations, and doing tasks in a consistent way to improve accuracy. (See TABLE 1.) They identified ways physicians bolster or hurt efficiency and ways in which the relationship between the physician and the MA shapes the MA’s perception of their value in clinic.

When asked about “pet peeves,” a few MAs advised that physicians should not “talk down” to staff and should try to teach rather than criticize.

Communication was emphasized as critical for efficient care, and MAs encouraged the use of preclinic huddles and communication as priorities. Seventy-five percent of MAs reported preclinic huddles to plan for patient care were helpful, but only half said huddles took place “always” or “most of the time.” Many described reviewing the schedule and completing tasks ahead of patient arrival as critical to efficiency.

Participants described the tension between their identified role of orchestrating clinic flow and responding to directives by others that disrupted the flow. Several MAs found it challenging when physicians agreed to see very late patients and felt frustrated when decisions that changed the flow were made by the physician or front desk staff without including the MA. MAs were also able to articulate how they managed competing priorities within the clinic, such as when a patient- or physician-driven need to extend appointments was at odds with maintaining a timely schedule. They were eager to share personal tips for time management and prided themselves on careful and accurate performance and skills they had learned on the job. MAs also described how efficiency could be adversely affected by the behaviors or attitudes of physicians. (See TABLE 2.)

Continue to: Clinic environment...

Clinic environment

Thirty-six MAs (59%) reported that other MAs on their team were willing to help them out in clinic “a great deal” or “a lot” of the time, by helping to room a patient, acting as a chaperone for an exam, or doing a point-of-care lab. This sense of support varied across clinics (38% to 91% reported good support), suggesting that cultures vary by site. Some MAs expressed frustration at peers they saw as resistant to helping, exemplified by this verbatim quote from an interview:

“Some don’t want to help out. They may sigh. It’s how they react—you just know.” (Clinic #1, MA #2 interview)

Efficient MAs stressed the need for situational awareness to recognize when co-workers need help:

“[Peers often] are not aware that another MA is drowning. There’s 5 people who could have done that, and here I am running around and nobody budged.” (Clinic #5, MA #2 interview)

A minority of staff used the open-ended survey sections to describe clinic hierarchy. When asked about “pet peeves,” a few advised that physicians should not “talk down” to staff and should try to teach rather than criticize. Another asked that physicians not “bark orders” or have “low gratitude” for staff work. MAs found micromanaging stressful—particularly when the physician prompted the MA about patient arrivals:

“[I don’t like] when providers will make a comment about a patient arriving when you already know this information. You then rush to put [the] patient in [a] room, then [the] provider ends up making [the] patient wait an extensive amount of time. I’m perfectly capable of knowing when a patient arrives.” (Clinic #6, survey)
 

MAs did not like physicians “talking bad about us” or blaming the MA if the clinic is running behind.
 

Despite these concerns, most MAs reported feeling appreciated for the job they do. Only 10 (16%) reported that the people they work with rarely say “thank you,” and 2 (3%) stated they were not well supported by the physicians in clinic. Most (n = 38; 62%) strongly agreed or agreed that they felt part of the team and that their opinions matter. In the interviews, many expanded on this idea:

“I really feel like I’m valued, so I want to do everything I can to make [my doctor’s] day go better. If you want a good clinic, the best thing a doc can do is make the MA feel valued.” (Clinic #1, MA #1 interview)

Continue to: DISCUSSION...

DISCUSSION

Participants described their role much as an orchestra director, with MAs as the key to clinic flow and timeliness.⁹ Respondents articulated multiple common strategies used to increase their own efficiency and clinic flow; these may be considered best practices and incorporated as part of the basic training. Most MAs reported their day-to-day jobs were stressful and believed this was underrecognized, so efficiency strategies are critical. With staff completing multiple time-sensitive tasks during clinic, consistent co-worker support is crucial and may impact efficiency.⁸ Proper training of managers to provide that support and ensure equitable workloads may be one strategy to ensure that staff members feel the workplace is fair and collegial.

Several comments reflected the power differential within medical offices. One study reported that MAs and physicians “occupy roles at opposite ends of social and occupational hierarchies.”¹¹ It’s important for physicians to be cognizant of these patterns and clinic culture, as reducing a hierarchy-based environment will be appreciated by MAs.⁹ Prior research has found that MAs have higher perceptions of their own competence than do the physicians working with them.¹² If there is a fundamental lack of trust between the 2 groups, this will undoubtedly hinder team-building. Attention to this issue is key to a more favorable work environment.

Almost all respondents reported health care was a “calling,” which mirrors physician research that suggests seeing work as a “calling” is protective against burnout.^13,14 Open-ended comments indicated great pride in contributions, and most staff members felt appreciated by their teams. Many described the working relationships with physicians as critical to their satisfaction at work and indicated that strong partnerships motivated them to do their best to make the physician’s day easier. Staff job satisfaction is linked to improved quality of care, so treating staff well contributes to high-value care for patients.¹⁵ We also uncovered some MA “pet peeves” that hinder efficiency and could be shared with physicians to emphasize the importance of patience and civility.

One barrier to expansion of MA roles within PCMH practices is the limited pay and career ladder for MAs who adopt new job responsibilities that require advanced skills or training.^1,2 The mean MA salary at our institution ($37,372) is higher than in our state overall ($33,760), which may impact satisfaction.¹⁶ In addition, 93% of MAs are women; thus, they may continue to struggle more with lower pay than do workers in male- dominated professions.^17,18 Expected job growth from 2018-2028 is predicted at 23%, which may help to boost salaries. ¹⁹  Prior studies describe the lack of a job ladder or promotion opportunities as a challenge^1,20; this was not formally assessed in our study.


Prior research has found that MAs have higher perceptions of their own competence than do the physicians working with them.

MAs see work in family medicine as much harder than it is in other   specialty clinics. Being trusted with more responsibility, greater autonomy,^21-23 and expanded patient care roles can boost MA self-efficacy, which can reduce burnout for both physicians and MAs. ^8,24  However, new responsibilities should include appropriate training, support, and compensation, and match staff interests.⁷

Study limitations. The study was limited to 6 clinics in 1 department at a large academic medical center. Interviewed participants were selected by convenience and snowball sampling and thus, the results cannot be generalized to the population of MAs as a whole. As the initial interview goal was simply to gather efficiency tips, the project was not designed to be formal qualitative research. However, the discussions built on open-ended comments from the written survey helped contextualize our quantitative findings about efficiency. Notes were documented in real time by a single interviewer with rapid typing skills, which allowed capture of quotes verbatim. Subsequent studies would benefit from more formal qualitative research methods (recording and transcribing interviews, multiple coders to reduce risk of bias, and more complex thematic analysis).

Our research demonstrated how MAs perceive their roles in primary care and the facilitators and barriers to high efficiency in the workplace, which begins to fill an important knowledge gap in primary care. Disseminating practices that staff members themselves have identified as effective, and being attentive to how staff members are treated, may increase individual efficiency while improving staff retention and satisfaction.

CORRESPONDENCE Katherine J. Gold, MD, MSW, MS, Department of Family Medicine and Department of Obstetrics and Gynecology, University of Michigan, 1018 Fuller Street, Ann Arbor, MI 48104-1213; [email protected]

ABSTRACT

Background: Medical assistant (MA) roles have expanded rapidly as primary care has evolved and MAs take on new patient care duties. Research that looks at the MA experience and factors that enhance or reduce efficiency among MAs is limited.

Methods: We surveyed all MAs working in 6 clinics run by a large academic family medicine department in Ann Arbor, Michigan. MAs deemed by peers as “most efficient” were selected for follow-up interviews. We evaluated personal strategies for efficiency, barriers to efficient care, impact of physician actions on efficiency, and satisfaction.

Results: A total of 75/86 MAs (87%) responded to at least some survey questions and 61/86 (71%) completed the full survey. We interviewed 18 MAs face to face. Most saw their role as essential to clinic functioning and viewed health care as a personal calling. MAs identified common strategies to improve efficiency and described the MA role to orchestrate the flow of the clinic day. Staff recognized differing priorities of patients, staff, and physicians and articulated frustrations with hierarchy and competing priorities as well as behaviors that impeded clinic efficiency. Respondents emphasized the importance of feeling valued by others on their team.

Conclusions: With the evolving demands made on MAs’ time, it is critical to understand how the most effective staff members manage their role and highlight the strategies they employ to provide efficient clinical care. Understanding factors that increase or decrease MA job satisfaction can help identify high-efficiency practices and promote a clinic culture that values and supports all staff.

As primary care continues to evolve into more team-based practice, the role of the medical assistant (MA) has rapidly transformed.¹ Staff may assist with patient management, documentation in the electronic medical record, order entry, pre-visit planning, and fulfillment of quality metrics, particularly in a Primary Care Medical Home (PCMH).² From 2012 through 2014, MA job postings per graduate increased from 1.3 to 2.3, suggesting twice as many job postings as graduates.³ As the demand for experienced MAs increases, the ability to recruit and retain high-performing staff members will be critical.

MAs are referenced in medical literature as early as the 1800s.⁴ The American Association of Medical Assistants was founded in 1956, which led to educational standardization and certifications.⁵ Despite the important role that MAs have long played in the proper functioning of a medical clinic—and the knowledge that team configurations impact a clinic’s efficiency and quality^6,7—few investigations have sought out the MA’s perspective.^8,9 Given the increasing clinical demands placed on all members of the primary care team (and the burnout that often results), it seems that MA insights into clinic efficiency could be valuable.

Continue to: Methods...

METHODS

This cross-sectional study was conducted from February to April 2019 at a large academic institution with 6 regional ambulatory care family medicine clinics, each one with 11,000 to 18,000 patient visits annually. Faculty work at all 6 clinics and residents at 2 of them. All MAs are hired, paid, and managed by a central administrative department rather than by the family medicine department. The family medicine clinics are currently PCMH certified, with a mix of fee-for-service and capitated reimbursement.

We developed and piloted a voluntary, anonymous 39-question (29 closed-ended and 10 brief open-ended) online Qualtrics survey, which we distributed via an email link to all the MAs in the department. The survey included clinic site, years as an MA, perceptions of the clinic environment, perception of teamwork at their site, identification of efficient practices, and feedback for physicians to improve efficiency and flow. Most questions were Likert-style with 5 choices ranging from “strongly agree” to “strongly disagree” or short answer. Age and gender were omitted to protect confidentiality, as most MAs in the department are female. Participants could opt to enter in a drawing for three $25 gift cards. The survey was reviewed by the University of Michigan Institutional Review Board and deemed exempt.
 

Seventy-five percent of MAs reported preclinic huddles to plan for patient care were helpful, but only half said huddles took place “always” or “most of the time.”

We asked MAs to nominate peers in their clinic who were “especially efficient and do their jobs well—people that others can learn from.” The staff members who were nominated most frequently by their peers were invited to share additional perspectives via a 10- to 30-minute semi-structured interview with the first author. Interviews covered highly efficient practices, barriers and facilitators to efficient care, and physician behaviors that impaired efficiency. We interviewed a minimum of 2 MAs per clinic and increased the number of interviews through snowball sampling, as needed, to reach data saturation (eg, the point at which we were no longer hearing new content). MAs were assured that all comments would be anonymized. There was no monetary incentive for the interviews. The interviewer had previously met only 3 of the 18 MAs interviewed.

Analysis. Summary statistics were calculated for quantitative data. To compare subgroups (such as individual clinics), a chi-square test was used. In cases when there were small cell sizes (< 5 subjects), we used the Fisher’s Exact test. Qualitative data was collected with real-time typewritten notes during the interviews to capture ideas and verbatim quotes when possible. We also included open-ended comments shared on the Qualtrics survey. Data were organized by theme using a deductive coding approach. Both authors reviewed and discussed observations, and coding was conducted by the first author. Reporting followed the STROBE Statement checklist for cross-sectional studies.¹⁰ Results were shared with MAs, supervisory staff, and physicians, which allowed for feedback and comments and served as “member-checking.” MAs reported that the data reflected their lived experiences.

Continue to: RESULTS...

RESULTS

Surveys were distributed to all 86 MAs working in family medicine clinics. A total of 75 (87%) responded to at least some questions (typically just demographics). We used those who completed the full survey (n = 61; 71%) for data analysis. Eighteen MAs participated in face-to-face interviews. Among respondents, 35 (47%) had worked at least 10 years as an MA and 21 (28%) had worked at least a decade in the family medicine department.

Perception of role

All respondents (n = 61; 100%) somewhat or strongly agreed that the MA role was “very important to keep the clinic functioning” and 58 (95%) reported that working in health care was “a calling” for them. Only 7 (11%) agreed that family medicine was an easier environment for MAs compared to a specialty clinic; 30 (49%) disagreed with this. Among respondents, 32 (53%) strongly or somewhat agreed that their work was very stressful and just half (n = 28; 46%) agreed there were adequate MA staff at their clinic.

Efficiency and competing priorities

MAs described important work values that increased their efficiency. These included clinic culture (good communication and strong teamwork), as well as individual strategies such as multitasking, limiting patient conversations, and doing tasks in a consistent way to improve accuracy. (See TABLE 1.) They identified ways physicians bolster or hurt efficiency and ways in which the relationship between the physician and the MA shapes the MA’s perception of their value in clinic.

When asked about “pet peeves,” a few MAs advised that physicians should not “talk down” to staff and should try to teach rather than criticize.

Communication was emphasized as critical for efficient care, and MAs encouraged the use of preclinic huddles and communication as priorities. Seventy-five percent of MAs reported preclinic huddles to plan for patient care were helpful, but only half said huddles took place “always” or “most of the time.” Many described reviewing the schedule and completing tasks ahead of patient arrival as critical to efficiency.

Participants described the tension between their identified role of orchestrating clinic flow and responding to directives by others that disrupted the flow. Several MAs found it challenging when physicians agreed to see very late patients and felt frustrated when decisions that changed the flow were made by the physician or front desk staff without including the MA. MAs were also able to articulate how they managed competing priorities within the clinic, such as when a patient- or physician-driven need to extend appointments was at odds with maintaining a timely schedule. They were eager to share personal tips for time management and prided themselves on careful and accurate performance and skills they had learned on the job. MAs also described how efficiency could be adversely affected by the behaviors or attitudes of physicians. (See TABLE 2.)

Continue to: Clinic environment...

Clinic environment

Thirty-six MAs (59%) reported that other MAs on their team were willing to help them out in clinic “a great deal” or “a lot” of the time, by helping to room a patient, acting as a chaperone for an exam, or doing a point-of-care lab. This sense of support varied across clinics (38% to 91% reported good support), suggesting that cultures vary by site. Some MAs expressed frustration at peers they saw as resistant to helping, exemplified by this verbatim quote from an interview:

“Some don’t want to help out. They may sigh. It’s how they react—you just know.” (Clinic #1, MA #2 interview)

Efficient MAs stressed the need for situational awareness to recognize when co-workers need help:

“[Peers often] are not aware that another MA is drowning. There’s 5 people who could have done that, and here I am running around and nobody budged.” (Clinic #5, MA #2 interview)

A minority of staff used the open-ended survey sections to describe clinic hierarchy. When asked about “pet peeves,” a few advised that physicians should not “talk down” to staff and should try to teach rather than criticize. Another asked that physicians not “bark orders” or have “low gratitude” for staff work. MAs found micromanaging stressful—particularly when the physician prompted the MA about patient arrivals:

“[I don’t like] when providers will make a comment about a patient arriving when you already know this information. You then rush to put [the] patient in [a] room, then [the] provider ends up making [the] patient wait an extensive amount of time. I’m perfectly capable of knowing when a patient arrives.” (Clinic #6, survey)
 

MAs did not like physicians “talking bad about us” or blaming the MA if the clinic is running behind.
 

Despite these concerns, most MAs reported feeling appreciated for the job they do. Only 10 (16%) reported that the people they work with rarely say “thank you,” and 2 (3%) stated they were not well supported by the physicians in clinic. Most (n = 38; 62%) strongly agreed or agreed that they felt part of the team and that their opinions matter. In the interviews, many expanded on this idea:

“I really feel like I’m valued, so I want to do everything I can to make [my doctor’s] day go better. If you want a good clinic, the best thing a doc can do is make the MA feel valued.” (Clinic #1, MA #1 interview)

Continue to: DISCUSSION...

DISCUSSION

Participants described their role much as an orchestra director, with MAs as the key to clinic flow and timeliness.⁹ Respondents articulated multiple common strategies used to increase their own efficiency and clinic flow; these may be considered best practices and incorporated as part of the basic training. Most MAs reported their day-to-day jobs were stressful and believed this was underrecognized, so efficiency strategies are critical. With staff completing multiple time-sensitive tasks during clinic, consistent co-worker support is crucial and may impact efficiency.⁸ Proper training of managers to provide that support and ensure equitable workloads may be one strategy to ensure that staff members feel the workplace is fair and collegial.

Several comments reflected the power differential within medical offices. One study reported that MAs and physicians “occupy roles at opposite ends of social and occupational hierarchies.”¹¹ It’s important for physicians to be cognizant of these patterns and clinic culture, as reducing a hierarchy-based environment will be appreciated by MAs.⁹ Prior research has found that MAs have higher perceptions of their own competence than do the physicians working with them.¹² If there is a fundamental lack of trust between the 2 groups, this will undoubtedly hinder team-building. Attention to this issue is key to a more favorable work environment.

Almost all respondents reported health care was a “calling,” which mirrors physician research that suggests seeing work as a “calling” is protective against burnout.^13,14 Open-ended comments indicated great pride in contributions, and most staff members felt appreciated by their teams. Many described the working relationships with physicians as critical to their satisfaction at work and indicated that strong partnerships motivated them to do their best to make the physician’s day easier. Staff job satisfaction is linked to improved quality of care, so treating staff well contributes to high-value care for patients.¹⁵ We also uncovered some MA “pet peeves” that hinder efficiency and could be shared with physicians to emphasize the importance of patience and civility.

One barrier to expansion of MA roles within PCMH practices is the limited pay and career ladder for MAs who adopt new job responsibilities that require advanced skills or training.^1,2 The mean MA salary at our institution ($37,372) is higher than in our state overall ($33,760), which may impact satisfaction.¹⁶ In addition, 93% of MAs are women; thus, they may continue to struggle more with lower pay than do workers in male- dominated professions.^17,18 Expected job growth from 2018-2028 is predicted at 23%, which may help to boost salaries. ¹⁹  Prior studies describe the lack of a job ladder or promotion opportunities as a challenge^1,20; this was not formally assessed in our study.


Prior research has found that MAs have higher perceptions of their own competence than do the physicians working with them.

MAs see work in family medicine as much harder than it is in other   specialty clinics. Being trusted with more responsibility, greater autonomy,^21-23 and expanded patient care roles can boost MA self-efficacy, which can reduce burnout for both physicians and MAs. ^8,24  However, new responsibilities should include appropriate training, support, and compensation, and match staff interests.⁷

Study limitations. The study was limited to 6 clinics in 1 department at a large academic medical center. Interviewed participants were selected by convenience and snowball sampling and thus, the results cannot be generalized to the population of MAs as a whole. As the initial interview goal was simply to gather efficiency tips, the project was not designed to be formal qualitative research. However, the discussions built on open-ended comments from the written survey helped contextualize our quantitative findings about efficiency. Notes were documented in real time by a single interviewer with rapid typing skills, which allowed capture of quotes verbatim. Subsequent studies would benefit from more formal qualitative research methods (recording and transcribing interviews, multiple coders to reduce risk of bias, and more complex thematic analysis).

Our research demonstrated how MAs perceive their roles in primary care and the facilitators and barriers to high efficiency in the workplace, which begins to fill an important knowledge gap in primary care. Disseminating practices that staff members themselves have identified as effective, and being attentive to how staff members are treated, may increase individual efficiency while improving staff retention and satisfaction.

CORRESPONDENCE Katherine J. Gold, MD, MSW, MS, Department of Family Medicine and Department of Obstetrics and Gynecology, University of Michigan, 1018 Fuller Street, Ann Arbor, MI 48104-1213; [email protected]

The Diagnosis: Plaque-type Syringoma

A biopsy demonstrated multiple basaloid islands of tumor cells in the reticular dermis with ductal differentiation, some with a commalike tail. The ducts were lined by 2 to 3 layers of small uniform cuboidal cells without atypia and contained inspissated secretions within the lumina of scattered ducts. There was an associated fibrotic collagenous stroma. There was no evidence of perineural invasion and no deep dermal or subcutaneous extension (Figure 1). Additional cytokeratin immunohistochemical staining highlighted the adnexal proliferation (Figure 2). A diagnosis of plaque-type syringoma (PTS) was made.

Syringomas are benign dermal sweat gland tumors that typically present as flesh-colored papules on the cheeks or periorbital area of young females. Plaque-type tumors as well as papulonodular, eruptive, disseminated, urticaria pigmentosa–like, lichen planus–like, or milialike syringomas also have been reported. Syringomas may be associated with certain medical conditions such as Down syndrome, Nicolau-Balus syndrome, and both scarring and nonscarring alopecias.¹ The clear cell variant of syringoma often is associated with diabetes mellitus.² Kikuchi et al³ first described PTS in 1979. Plaque-type syringomas rarely are reported in the literature, and sites of involvement include the head and neck region, upper lip, chest, upper extremities, vulva, penis, and scrotum.^4-6

Histologically, syringomatous lesions are composed of multiple small ducts lined by 2 to 3 layers of cuboidal epithelium. The ducts may be arranged in nests or strands of basaloid cells surrounded by a dense fibrotic stroma. Occasionally, the ducts will form a comma- or teardropshaped tail; however, this also may be observed in desmoplastic trichoepithelioma (DTE).⁷ Perineural invasion is absent in syringomas. Syringomas exhibit a lateral growth pattern that typically is limited to the upper half of the reticular dermis and spares the underlying subcutis, muscle, and bone. The growth pattern may be discontinuous with proliferations juxtaposed by normal-appearing skin.⁸ Syringomas usually express progesterone receptors and are known to proliferate at puberty, suggesting that these neoplasms are under hormonal control.⁹ Although syringomas are benign, various treatment options that may be pursued for cosmetic purposes include radiofrequency, staged excision, laser ablation, and oral isotretinoin.^8,10 If only a superficial biopsy is obtained, syringomas may display features of other adnexal neoplasms, including microcystic adnexal carcinoma (MAC), DTE, morpheaform basal cell carcinoma (BCC), and inflammatory linear verrucous epidermal nevus (ILVEN).

Microcystic adnexal carcinoma is a locally aggressive neoplasm first described by Goldstein et al¹¹ in 1982 an indurated, ill-defined plaque or nodule on the face with a predilection for the upper and lower lip. Prior radiation therapy and immunosuppression are risk factors for the development of MAC.¹² Histologically, the superficial portion displays small cornifying cysts interspersed with islands of basaloid cells and may mimic a syringoma. However, the deeper portions demonstrate ducts lined by a single layer of cells with a background of hyalinized and sclerotic stroma. The tumor cells may occupy the deep dermis and underlying subcutis, muscle, or bone and demonstrate an infiltrative growth pattern and perineural invasion. Treatment includes Mohs micrographic surgery.

Desmoplastic trichoepitheliomas most commonly present as solitary white to yellowish annular papules or plaques with a central dell located on sun-exposed areas of the face, cheeks, or chin. This benign neoplasm has a bimodal age distribution, primarily affecting females either in childhood or adulthood.¹³ Histologically, strands and nests of basaloid epithelial cells proliferate in a dense eosinophilic desmoplastic stroma. The basaloid islands are narrow and cordlike with growth parallel to the surface epidermis and do not dive deeply into the deep dermis or subcutis. Ductal differentiation with associated secretions typically is not seen in DTE.¹ Calcifications and foreign body granulomatous infiltrates may be present. Merkel cells also are present in this tumor and may be highlighted by immunohistochemistry with cytokeratin 20.¹⁴ Rarely, desmoplastic trichoepitheliomas may transform into trichoblastic carcinomas. Treatment may consist of surgical excision or Mohs micrographic surgery.

Morpheaform BCC also is included in the clinical and histopathologic differential diagnosis of infiltrative basaloid neoplasms. It is one of the more aggressive variants of BCC. The use of immunohistochemical staining may aid in differentiating between these sclerosing adnexal neoplasms.¹⁵ For example, pleckstrin homologylike domain family A member 1 (PHLDA1) is a stem cell marker that is heavily expressed in DTE as a specific follicular bulge marker but is not present in a morpheaform BCC. This highlights the follicular nature of DTEs at the molecular level. BerEP4 is a monoclonal antibody that serves as an epithelial marker for 2 glycopolypeptides: 34 and 39 kDa. This antibody may demonstrate positivity in morpheaform BCC but does not stain cells of interest in MAC.

Inflammatory linear verrucous epidermal nevus clinically presents with erythematous and warty papules in a linear distribution following the Blaschko lines. The papules often are reported to be intensely pruritic and usually are localized to one extremity.¹⁶ Although adultonset forms of ILVEN have been described,¹⁷ it most commonly is diagnosed in young children. Histologically, ILVEN consists of psoriasiform epidermal hyperplasia with alternating areas of parakeratosis and orthokeratosis with underlying agranulosis and hypergranulosis, respectively.¹⁸ The upper dermis contains a perivascular lymphocytic infiltrate. Treatment with laser therapy and surgical excision has led to both symptomatic and clinical improvement of ILVEN.¹⁶

Plaque-type syringomas are a rare variant of syringomas that clinically may mimic other common inflammatory and neoplastic conditions. An adequate biopsy is imperative to differentiate between adnexal neoplasms, as a small superficial biopsy of a syringoma may demonstrate features observed in other malignant or locally aggressive neoplasms. In our patient, the small ducts lined by cuboidal epithelium with no cellular atypia and no deep dermal growth or perineural invasion allowed for the diagnosis of PTS. Therapeutic options were reviewed with our patient, including oral isotretinoin, laser therapy, and staged excision. Ultimately, our patient elected not to pursue treatment, and she is being monitored clinically for any changes in appearance or symptoms.

The Diagnosis: Plaque-type Syringoma

A biopsy demonstrated multiple basaloid islands of tumor cells in the reticular dermis with ductal differentiation, some with a commalike tail. The ducts were lined by 2 to 3 layers of small uniform cuboidal cells without atypia and contained inspissated secretions within the lumina of scattered ducts. There was an associated fibrotic collagenous stroma. There was no evidence of perineural invasion and no deep dermal or subcutaneous extension (Figure 1). Additional cytokeratin immunohistochemical staining highlighted the adnexal proliferation (Figure 2). A diagnosis of plaque-type syringoma (PTS) was made.

Syringomas are benign dermal sweat gland tumors that typically present as flesh-colored papules on the cheeks or periorbital area of young females. Plaque-type tumors as well as papulonodular, eruptive, disseminated, urticaria pigmentosa–like, lichen planus–like, or milialike syringomas also have been reported. Syringomas may be associated with certain medical conditions such as Down syndrome, Nicolau-Balus syndrome, and both scarring and nonscarring alopecias.¹ The clear cell variant of syringoma often is associated with diabetes mellitus.² Kikuchi et al³ first described PTS in 1979. Plaque-type syringomas rarely are reported in the literature, and sites of involvement include the head and neck region, upper lip, chest, upper extremities, vulva, penis, and scrotum.^4-6

Histologically, syringomatous lesions are composed of multiple small ducts lined by 2 to 3 layers of cuboidal epithelium. The ducts may be arranged in nests or strands of basaloid cells surrounded by a dense fibrotic stroma. Occasionally, the ducts will form a comma- or teardropshaped tail; however, this also may be observed in desmoplastic trichoepithelioma (DTE).⁷ Perineural invasion is absent in syringomas. Syringomas exhibit a lateral growth pattern that typically is limited to the upper half of the reticular dermis and spares the underlying subcutis, muscle, and bone. The growth pattern may be discontinuous with proliferations juxtaposed by normal-appearing skin.⁸ Syringomas usually express progesterone receptors and are known to proliferate at puberty, suggesting that these neoplasms are under hormonal control.⁹ Although syringomas are benign, various treatment options that may be pursued for cosmetic purposes include radiofrequency, staged excision, laser ablation, and oral isotretinoin.^8,10 If only a superficial biopsy is obtained, syringomas may display features of other adnexal neoplasms, including microcystic adnexal carcinoma (MAC), DTE, morpheaform basal cell carcinoma (BCC), and inflammatory linear verrucous epidermal nevus (ILVEN).

Microcystic adnexal carcinoma is a locally aggressive neoplasm first described by Goldstein et al¹¹ in 1982 an indurated, ill-defined plaque or nodule on the face with a predilection for the upper and lower lip. Prior radiation therapy and immunosuppression are risk factors for the development of MAC.¹² Histologically, the superficial portion displays small cornifying cysts interspersed with islands of basaloid cells and may mimic a syringoma. However, the deeper portions demonstrate ducts lined by a single layer of cells with a background of hyalinized and sclerotic stroma. The tumor cells may occupy the deep dermis and underlying subcutis, muscle, or bone and demonstrate an infiltrative growth pattern and perineural invasion. Treatment includes Mohs micrographic surgery.

Desmoplastic trichoepitheliomas most commonly present as solitary white to yellowish annular papules or plaques with a central dell located on sun-exposed areas of the face, cheeks, or chin. This benign neoplasm has a bimodal age distribution, primarily affecting females either in childhood or adulthood.¹³ Histologically, strands and nests of basaloid epithelial cells proliferate in a dense eosinophilic desmoplastic stroma. The basaloid islands are narrow and cordlike with growth parallel to the surface epidermis and do not dive deeply into the deep dermis or subcutis. Ductal differentiation with associated secretions typically is not seen in DTE.¹ Calcifications and foreign body granulomatous infiltrates may be present. Merkel cells also are present in this tumor and may be highlighted by immunohistochemistry with cytokeratin 20.¹⁴ Rarely, desmoplastic trichoepitheliomas may transform into trichoblastic carcinomas. Treatment may consist of surgical excision or Mohs micrographic surgery.

Morpheaform BCC also is included in the clinical and histopathologic differential diagnosis of infiltrative basaloid neoplasms. It is one of the more aggressive variants of BCC. The use of immunohistochemical staining may aid in differentiating between these sclerosing adnexal neoplasms.¹⁵ For example, pleckstrin homologylike domain family A member 1 (PHLDA1) is a stem cell marker that is heavily expressed in DTE as a specific follicular bulge marker but is not present in a morpheaform BCC. This highlights the follicular nature of DTEs at the molecular level. BerEP4 is a monoclonal antibody that serves as an epithelial marker for 2 glycopolypeptides: 34 and 39 kDa. This antibody may demonstrate positivity in morpheaform BCC but does not stain cells of interest in MAC.

Inflammatory linear verrucous epidermal nevus clinically presents with erythematous and warty papules in a linear distribution following the Blaschko lines. The papules often are reported to be intensely pruritic and usually are localized to one extremity.¹⁶ Although adultonset forms of ILVEN have been described,¹⁷ it most commonly is diagnosed in young children. Histologically, ILVEN consists of psoriasiform epidermal hyperplasia with alternating areas of parakeratosis and orthokeratosis with underlying agranulosis and hypergranulosis, respectively.¹⁸ The upper dermis contains a perivascular lymphocytic infiltrate. Treatment with laser therapy and surgical excision has led to both symptomatic and clinical improvement of ILVEN.¹⁶

Plaque-type syringomas are a rare variant of syringomas that clinically may mimic other common inflammatory and neoplastic conditions. An adequate biopsy is imperative to differentiate between adnexal neoplasms, as a small superficial biopsy of a syringoma may demonstrate features observed in other malignant or locally aggressive neoplasms. In our patient, the small ducts lined by cuboidal epithelium with no cellular atypia and no deep dermal growth or perineural invasion allowed for the diagnosis of PTS. Therapeutic options were reviewed with our patient, including oral isotretinoin, laser therapy, and staged excision. Ultimately, our patient elected not to pursue treatment, and she is being monitored clinically for any changes in appearance or symptoms.

The Diagnosis: Plaque-type Syringoma

A biopsy demonstrated multiple basaloid islands of tumor cells in the reticular dermis with ductal differentiation, some with a commalike tail. The ducts were lined by 2 to 3 layers of small uniform cuboidal cells without atypia and contained inspissated secretions within the lumina of scattered ducts. There was an associated fibrotic collagenous stroma. There was no evidence of perineural invasion and no deep dermal or subcutaneous extension (Figure 1). Additional cytokeratin immunohistochemical staining highlighted the adnexal proliferation (Figure 2). A diagnosis of plaque-type syringoma (PTS) was made.

Syringomas are benign dermal sweat gland tumors that typically present as flesh-colored papules on the cheeks or periorbital area of young females. Plaque-type tumors as well as papulonodular, eruptive, disseminated, urticaria pigmentosa–like, lichen planus–like, or milialike syringomas also have been reported. Syringomas may be associated with certain medical conditions such as Down syndrome, Nicolau-Balus syndrome, and both scarring and nonscarring alopecias.¹ The clear cell variant of syringoma often is associated with diabetes mellitus.² Kikuchi et al³ first described PTS in 1979. Plaque-type syringomas rarely are reported in the literature, and sites of involvement include the head and neck region, upper lip, chest, upper extremities, vulva, penis, and scrotum.^4-6

Histologically, syringomatous lesions are composed of multiple small ducts lined by 2 to 3 layers of cuboidal epithelium. The ducts may be arranged in nests or strands of basaloid cells surrounded by a dense fibrotic stroma. Occasionally, the ducts will form a comma- or teardropshaped tail; however, this also may be observed in desmoplastic trichoepithelioma (DTE).⁷ Perineural invasion is absent in syringomas. Syringomas exhibit a lateral growth pattern that typically is limited to the upper half of the reticular dermis and spares the underlying subcutis, muscle, and bone. The growth pattern may be discontinuous with proliferations juxtaposed by normal-appearing skin.⁸ Syringomas usually express progesterone receptors and are known to proliferate at puberty, suggesting that these neoplasms are under hormonal control.⁹ Although syringomas are benign, various treatment options that may be pursued for cosmetic purposes include radiofrequency, staged excision, laser ablation, and oral isotretinoin.^8,10 If only a superficial biopsy is obtained, syringomas may display features of other adnexal neoplasms, including microcystic adnexal carcinoma (MAC), DTE, morpheaform basal cell carcinoma (BCC), and inflammatory linear verrucous epidermal nevus (ILVEN).

Microcystic adnexal carcinoma is a locally aggressive neoplasm first described by Goldstein et al¹¹ in 1982 an indurated, ill-defined plaque or nodule on the face with a predilection for the upper and lower lip. Prior radiation therapy and immunosuppression are risk factors for the development of MAC.¹² Histologically, the superficial portion displays small cornifying cysts interspersed with islands of basaloid cells and may mimic a syringoma. However, the deeper portions demonstrate ducts lined by a single layer of cells with a background of hyalinized and sclerotic stroma. The tumor cells may occupy the deep dermis and underlying subcutis, muscle, or bone and demonstrate an infiltrative growth pattern and perineural invasion. Treatment includes Mohs micrographic surgery.

Desmoplastic trichoepitheliomas most commonly present as solitary white to yellowish annular papules or plaques with a central dell located on sun-exposed areas of the face, cheeks, or chin. This benign neoplasm has a bimodal age distribution, primarily affecting females either in childhood or adulthood.¹³ Histologically, strands and nests of basaloid epithelial cells proliferate in a dense eosinophilic desmoplastic stroma. The basaloid islands are narrow and cordlike with growth parallel to the surface epidermis and do not dive deeply into the deep dermis or subcutis. Ductal differentiation with associated secretions typically is not seen in DTE.¹ Calcifications and foreign body granulomatous infiltrates may be present. Merkel cells also are present in this tumor and may be highlighted by immunohistochemistry with cytokeratin 20.¹⁴ Rarely, desmoplastic trichoepitheliomas may transform into trichoblastic carcinomas. Treatment may consist of surgical excision or Mohs micrographic surgery.

Morpheaform BCC also is included in the clinical and histopathologic differential diagnosis of infiltrative basaloid neoplasms. It is one of the more aggressive variants of BCC. The use of immunohistochemical staining may aid in differentiating between these sclerosing adnexal neoplasms.¹⁵ For example, pleckstrin homologylike domain family A member 1 (PHLDA1) is a stem cell marker that is heavily expressed in DTE as a specific follicular bulge marker but is not present in a morpheaform BCC. This highlights the follicular nature of DTEs at the molecular level. BerEP4 is a monoclonal antibody that serves as an epithelial marker for 2 glycopolypeptides: 34 and 39 kDa. This antibody may demonstrate positivity in morpheaform BCC but does not stain cells of interest in MAC.

Inflammatory linear verrucous epidermal nevus clinically presents with erythematous and warty papules in a linear distribution following the Blaschko lines. The papules often are reported to be intensely pruritic and usually are localized to one extremity.¹⁶ Although adultonset forms of ILVEN have been described,¹⁷ it most commonly is diagnosed in young children. Histologically, ILVEN consists of psoriasiform epidermal hyperplasia with alternating areas of parakeratosis and orthokeratosis with underlying agranulosis and hypergranulosis, respectively.¹⁸ The upper dermis contains a perivascular lymphocytic infiltrate. Treatment with laser therapy and surgical excision has led to both symptomatic and clinical improvement of ILVEN.¹⁶

Plaque-type syringomas are a rare variant of syringomas that clinically may mimic other common inflammatory and neoplastic conditions. An adequate biopsy is imperative to differentiate between adnexal neoplasms, as a small superficial biopsy of a syringoma may demonstrate features observed in other malignant or locally aggressive neoplasms. In our patient, the small ducts lined by cuboidal epithelium with no cellular atypia and no deep dermal growth or perineural invasion allowed for the diagnosis of PTS. Therapeutic options were reviewed with our patient, including oral isotretinoin, laser therapy, and staged excision. Ultimately, our patient elected not to pursue treatment, and she is being monitored clinically for any changes in appearance or symptoms.