Incorporating Cosmetic Training Into Resident Education
Cosmetic procedures have been increasing in popularity, and the vast majority of the growth has been in the minimally invasive arena. In 2017, dermatologic surgeons surveyed by the American Society for Dermatologic Surgery (ASDS) reported performing an estimated 8 million cosmetic procedures.1 Since the inception of cosmetic medicine, innovative dermatologists have been at the forefront of this movement, having pioneered many of the devices and techniques that are now part of the standard practice including lasers, tumescent liposuction, neuromodulators, fillers, chemical peels, and fat reduction/body contouring.2,3
The Importance of Teaching Aesthetic Dermatology
Dermatologists are perceived by the public as well as our fellow physicians to be experts in cosmetic procedures. A 2012 survey revealed that primary care physicians perceive dermatologists as the most qualified specialists to perform neuromodulator, filler, and laser procedures.4 And a 2018 ASDS Consumer Survey also found dermatologists to be the most influential in their decision on whether to undergo a cosmetic procedure.5 In order to maintain the collective expertise and reputation of our specialty in aesthetic medicine, we must continue to uphold high standards in resident education.
It appears that a large portion of dermatology residents in the United States plan to incorporate cosmetics into their practices to some degree; surveys of US dermatology residents have reported that 75% to 99% of residents plan to include cosmetic procedures in their practice.6-8 Because most residents do not pursue cosmetic fellowships, the skills and knowledge gained during residency become the foundation upon which future expertise is built.
Most importantly, we owe it to our patients to train our residents to ensure that they have the knowledge and skill to safely and competently perform these procedures. We must ensure that residents are receiving accurate and unbiased information, especially because much of the post-residency cosmetic training is industry-sponsored. Just as importantly, they should also know their limitations as well as how to manage potential complications. Even residents who do not plan to perform any aesthetic procedures should still have enough familiarity with the procedures, the indications, contraindications, and potential complications to properly counsel and refer patients to the appropriate providers.
Accreditation Requirements
Currently, the Accreditation Council for Graduate Medical Education (ACGME) requires dermatology residents to demonstrate knowledge of the indications, contraindications, complications, and basic techniques of elective cosmetic procedures including botulinum toxin injection, fillers, laser and other energy-based devices, chemical peels, dermabrasion, hair transplantation, invasive vein therapies, liposuction, scar revision, and sclerotherapy.9 Education regarding these topics may be via didactic sessions such as lectures or video instruction. Currently, the ACGME also requires that residents either perform or observe 10 neuromodulator procedures, five filler procedures, and 15 laser procedures. Each resident must maintain a case log of these procedures and review the documentation with a faculty member in their program. Currently, the ACGME Dermatology Residency Review Committee is reviewing a proposal to increase the required number of cases for neuromodulators, fillers, laser procedures, and chemical peels and to require that the resident perform the procedures as the primary surgeon rather than as an observer.
Sources of Cosmetic Education
In the United States, most dermatology residents receive their cosmetic education through a variety of modalities, including lectures/didactics, textbooks, journals articles, observation in faculty clinics, and hands-on workshops.6-8 Additional sources of cosmetic education available to residents include local, regional, and national courses and conferences; industry-driven education sessions; online resources including those available through national societies such as the ASDS; social media; and online forums/discussion groups.
All ACGME-accredited dermatology residency programs are required to provide didactics, either by core or adjunct faculty. Most programs also provide hands-on workshops for residents to develop their procedural skills, as shown by surveys of residency program directors and residents.6-8,10 Some programs begin hands-on training during their first year of dermatology training, while others incorporate it later in residency. A 2012 survey of third-year residents demonstrated that earlier exposure to cosmetic procedures resulted in more familiarity with that particular procedure.6 Residents have the opportunity for hands-on training most commonly with lasers and injectable procedures (neuromodulators, fillers, sclerotherapy), while exposure to procedures such as liposuction and hair transplantation typically occurs through didactics.11
From a resident perspective, most residents report that they want more cosmetic training during residency, and most prefer active learning techniques such as hands-on training over lectures or assigned reading.6-8 Among dermatology residents surveyed in 2018, the vast majority reported that hands-on training was most helpful (89%) compared with assigned reading (4%), assisting (3%), conference attendance, or lectures (each 2%).7 Over the past several years, resident expectation for developing competence in cosmetic procedures during the course of their residency has also increased.8
A 2012 survey of third-year residents revealed that the use of virtual reality simulator models was not associated with familiarity of any cosmetic procedures, but the apprenticeship model (observing and assisting a faculty member performing the procedure) was more helpful.6
The reality is that learning cannot occur in a vacuum. Although hands-on training is invaluable, residents also need to learn the fundamentals of cosmetic procedures through didactics, reading assignments, and observation of skilled providers before “diving in” to practice on patients.
In our program, the cosmetic curriculum encompasses didactics, observation, and assisting in faculty clinics, as well as several hands-on sessions throughout the year. Residents receive didactics on neuromodulators, fillers, lasers and other energy-based procedures, chemical peels, fat removal and body contouring, vein treatment, dermabrasion, and hair transplantation by core faculty. We also invite faculty from other departments (plastic and facial plastic surgery) and outside institutions to give lectures.
A significant component of the cosmetic training of our residents is through an apprenticeship model, which involves residents observing and assisting in faculty cosmetic clinics throughout their training. Once a resident has demonstrated a sufficient degree of knowledge and observational skill, we will book a few patients to be treated by the resident during their cosmetic rotation. This is a good opportunity for one-on-one teaching of the technical aspects of the procedure. Residents report that the time in faculty clinics allows them the opportunity to observe the nuances and finer points of seemingly simple procedures and to ask questions to fine-tune their skills.
In faculty clinics, residents also learn many of the practical aspects of a cosmetic practice, such as how to conduct a cosmetic consultation, setting patient expectations, time management, maintaining and caring for laser equipment, the ergonomics of cosmetic and laser procedures, managing inventory of products, teaching and managing staff, and the economic aspects of a cosmetic practice.
Five to six times per year, our residents participate in hands-on sessions to gain experience with neuromodulators, fillers, deoxycholate injections, chemical peels, sclerotherapy, and lasers and light-based procedures (vascular lasers, fractional nonablative, pigment lasers, hair removal, intense pulsed light). In four of these sessions, residents serve as the primary surgeon to treat patients under supervision of faculty. Patients must be comfortable with having one or more residents performing the procedure and with having additional observers (other residents, medical students, visiting rotators) in the room. We have found it most helpful to recruit patients who have an interest in the educational process and are willing to provide constructive feedback to residents. Most of our resident cosmetic patients are self-selected to receive care in an academic teaching hospital setting.
Twice per year we hold a “friends and family” session, during which residents have an opportunity to treat family members, friends, and staff. These are especially helpful in that residents feel more comfortable asking the person being treated to provide real-time honest feedback and are also able to follow patients’ post-treatment course more closely. Many of our departmental staff have volunteered to be patients for trainees, and they have been especially helpful in providing feedback and follow up.
Overcoming Potential Barriers to Aesthetic Training
Although there has been a trend toward more residency programs incorporating cosmetic training into their curriculum, barriers to cosmetic training still exist. Waldman et al has highlighted educational and practice gaps in cosmetic dermatology12; residency training is a fundamental starting point for addressing the educational gaps. A survey of program directors published in 2014 revealed that some program directors feel that there is no role for cosmetic training during residency, and only 38% felt that cosmetic training should be a necessary part of dermatology residency.10 Two separate surveys of dermatology residents each revealed that 22% of respondents felt that their programs were unsupportive of cosmetic training, and 20% to 38% reported their programs were neutral with regard to cosmetic training.6,7 With regard to education on skin care and cosmeceuticals, one study reported that more than three-quarters of resident respondents felt that skin care and cosmeceutical education should be part of their education. Almost 75% report their education on this topic has been “too little or nonexistent”, whereas 60% of faculty respondents reported that the resident education in this area is “just the right amount or too much.”13 Among Canadian respondents, both residents and faculty surveyed felt the need to incorporate more cosmetic training into the residency curriculum.14
Another potential barrier is the lack of core faculty in the program who perform these procedures on a regular basis. Some programs overcome this barrier by having residents learn from private practice or volunteer faculty in various capacities, including didactics, observation, or hands-on workshops. A significant percentage of residents have reported that their programs rely on dermatologists in private practice for didactics (31%). In fact, many of the nationally recognized experts in aesthetic dermatology practice in private rather than academic settings, and it benefits residents to have access to their expertise. Other resources include videos of procedures or tapping into the expertise of faculty in other departments.
Another reported barrier is that it can be difficult to recruit patients who are willing to allow a trainee to perform the procedures. One strategy some programs employ is to offer the procedures at a discount or free of charge in some programs. Another method to overcome this barrier is to have the residents treat staff, friends, or family members who may be more willing to undergo the procedures with a trainee.
Additional resources for residents whose programs offer limited aesthetic training include national and regional conferences sponsored by organizations such as the ASDS and Cosmetic Boot Camp, and many residents use these conferences to supplement their cosmetic education.8 Some of these courses are tailored to residents and incorporate lectures on anatomy and fundamentals, in addition to live or video demonstration and, in some cases, hands-on training on simulation models.
Future Considerations
Dermatology residency programs have ambivalent attitudes toward teaching residents aesthetic procedures, and there is disagreement regarding how much time should be devoted to cosmetic training.15 Some faculty have expressed concern that if more time is spent on cosmetics, there will be less time available to teach and decreased interest in medical dermatology. A 2008 survey of dermatology chairs and program directors reported that, of 53 respondents, 85% felt that an increasing percentage of time had been devoted to cosmetic education, and 53% believed that it had resulted in decreased expertise and decreased interest in medical dermatology.16 However, third-year residents who were surveyed revealed that, although 75% of respondents planned to incorporate cosmetic procedures into their practice, 98% were not less likely to practice medical dermatology as a result of their training in cosmetic dermatology.6 While it is true that dermatologists have as a whole devoted an increasing portion of their practices to cosmetic dermatology over the past couple decades, the majority of dermatology residency graduates will continue to practice medical dermatology and will incorporate cosmetic procedures to varying extents, according to these survey results.
As the popularity of cosmetic procedures has increased, so have the number and range of providers offering these services. Training and oversight of cosmetic providers can be quite variable, and the risk of complications is concerning. A 2014 study revealed increase risk of litigation in laser procedures when provided by nonphysician provider.17 State rules governing oversight requirements for laser and energy-based procedures are heterogeneous.18 Dermatologists are often in a position to oversee physician assistants, nurse practitioners, nurses, and laser technicians; therefore, they need to have the expertise to teach and supervise these procedures. As the experts in care of the skin, it is imperative that dermatologists are well versed in potential complications of aesthetic procedures—whether or not they practice aesthetic dermatology—and know how to treat the complications or to whom they should refer the patients for further management.
Training in aesthetic dermatology and lasers also encompasses a wide range of indications beyond purely the cosmetic, such as treatment of disfiguring birthmarks, scars, and morphea lesions, improving range of motion and function in burn patients, and treating alopecia of various causes. This is especially true in an academic setting where interdisciplinary referrals foster collaboration and scientific inquiry. The science of aesthetics can overlap with other scientific areas, including regenerative medicine, psychiatry, and biomedical engineering, to just name a few, and we should encourage and support our trainees who are interested in progressing our field. The practice of cosmetic medicine deserves the same rigor, oversight, and scientific inquiry as other fields of medicine.
Dr Sheu is director of the Cosmetic and Laser Program and assistant professor in the department of dermatology at Johns Hopkins University, Baltimore, MD.
Disclosure: Dr Sheu has no financial relationships to disclose.
References
1. American Society of Dermatologic Surgery (ASDS). ASDS 2017 Survey on Dermatologic Procedures. ASDS website. https://www.asds.net/medical-professionals/practice-resources/asds-survey-on-dermatologic-procedures. Accessed August 28, 2019.
2. Coleman WP 3rd, Hanke CW, Orentreich N, et al. A history of dermatologic surgery in the United States. Dermatol Surg. 2000;26(1):5-11.
3. Bangash HK, Eisen DB, Armstrong AW, et al. Who are the pioneers? A critical analysis of innovation and expertise in cutaneous noninvasive and minimally invasive cosmetic and surgical procedures. Dermatol Surg. 2016;42(3):335-351.
4. Ibrahimi OA, Bangash H, Green L, et al. Perceptions of expertise in cutaneous surgery and cosmetic procedures: what primary care physicians think. Dermatol Surg. 2012;38(10):1645-1651.
5. American Society of Dermatologic Surgery (ASDS). ASDS 2018 Consumer Survey on Dermatologic Cosmetic Procedures. ASDS website. https://www.asds.net/medical-professionals/practice-resources/asds-consumer-survey-on-cosmetic-dermatologic-procedures. Accessed August 28, 2019.
6. Group A, Philips R, Kelly E. Cosmetic dermatology training in residency: results of a survey from the residents’ perspective. Dermatol Surg. 2012;38(12):1975-1980.
7. Champlain A, Reserva J, Webb K, et al. Cosmetic dermatology training during residency: outcomes of a resident-reported survey. Dermatol Surg. 2018;44(9):1216-1219.
8. Kirby JS, Adgerson CN, Anderson BE. A survey of dermatology resident education in cosmetic procedures. J Am Acad Dermatol. 2013;68(2):e23-e28.
9. Accreditation Council on Graduate Medical Education Requirements. ACGME.org.
10. Bauer B, Williams E, Stratman EJ. Cosmetic dermatologic surgical training in US dermatology residency programs: identifying and overcoming barriers. JAMA Dermatol. 2014;150(2):125-129.
11. Lee EH, Nehal KS, Dusza SW, Hale EK, Levine VJ. Procedural dermatology training during dermatology residency: a survey of third-year dermatology residents.
J Am Acad Dermatol. 2011;64(3):475-483.
12. Waldman A, Sobanko JF, Alam M. Practice and educational gaps in cosmetic dermatologic surgery. Dermatol Clin. 2016;34(3):341-346.
13. Feetham HJ, Jeong HS, McKesey J, Wickless H, Jacobe H. Skin care and cosmeceuticals: Attitudes and trends among trainees and educators. J Cosmet Dermatol. 2018;17(2):220-226.
14. Worley B, Verma L, Macdonald J. Aesthetic dermatologic surgery training in Canadian residency programs. J Cutan Med Surg. 2019;23(2):164-173.
15. Reichel JL, Peirson RP, Berg D. Teaching and evaluation of surgical skills in dermatology: results of a survey. Arch Dermatol. 2004;140(11):1365-1369.
16. Schleichert R, Hostetler SG, Zirwas M. The perceived influence of cosmetic dermatology on dermatology resident education. J Am Acad Dermatol. 2010;63(2):352-353.
17. Jalian HR, Jalian CA, Avram MM. Increased risk of litigation associated with laser surgery by nonphysician operators. JAMA Dermatol. 2014;150(4):407-411.
18. DiGiorgio CM, Avram MM. Laws and regulations of laser operation in the United States. Lasers Surg Med. 2018;50(4):272-279.
