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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 25  |  Issue : 2  |  Page : 87-94

Dermatologic surgery training in dermatology residency programs in Saudi Arabia: A cross-sectional survey


Department of Dermatology, King Saud University, Riyadh, Saudi Arabia

Date of Submission10-May-2021
Date of Acceptance09-Jun-2021
Date of Web Publication29-Mar-2022

Correspondence Address:
Dr. Norah Alsubait
Almishwar, Alwadi Neighbor, 8138/2, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdds.jdds_42_21

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  Abstract 


Background: Dermatologic surgical procedures are expanding. Residents' training in procedural dermatology must evolve with the changes in the field. Purpose: We assessed the current status of surgical dermatology training in all Saudi Commission for Health Specialties (SCFHS)-accredited dermatology residency programs in Saudi Arabia. Methods: The survey was mailed to all 4th-year dermatology residents who completed the full 4 years of training at 5 SCFHS-accredited dermatology residency programs in December 2020. Statistical software SPSS (Version 22) was used to analyze responses. Results: A total of 26 4th-year residents participated, with a response rate of 89.6%. About 53.8% of the participants were equally assigned as the primary surgeons in laser for acne scar treatment and botulinum toxin for hyperhidrosis. Most of residents reported higher levels of nonexposure, especially for hair transplant procedures at 88.5%, fat transfer at 84.6%, fillers injection, and chemical peels at 65.4%. Regarding Mohs surgery, 73.1% of them are only knowledgeable through lectures and observations, without any hands-on training. The majority of residents (92.3%) were not satisfied with their dermatologic surgery training during residency. Conclusion: Residents express dissatisfaction with procedural and surgical dermatology training. Exposure in important areas of dermatologic surgery training could be better.

Keywords: Dermatologic surgery, procedural dermatology, residency training


How to cite this article:
Alsubait N, Mitwalli H. Dermatologic surgery training in dermatology residency programs in Saudi Arabia: A cross-sectional survey. J Dermatol Dermatol Surg 2021;25:87-94

How to cite this URL:
Alsubait N, Mitwalli H. Dermatologic surgery training in dermatology residency programs in Saudi Arabia: A cross-sectional survey. J Dermatol Dermatol Surg [serial online] 2021 [cited 2022 Aug 16];25:87-94. Available from: https://www.jddsjournal.org/text.asp?2021/25/2/87/341209




  Introduction Top


Dermatology practice encompasses an evolving array of cutaneous oncologic, cosmetic, and laser procedures. Adequate training in these dermatologic surgery procedures is an essential aspect of dermatology residency programs.[1],[2] The Saudi Board of Dermatology, accredited by the Saudi Commission for Health Specialties (SCFHS), requires residents to have an understanding of the majority of cutaneous procedures and laser applications.[3] Furthermore, the board requires residents to be familiar with a variety of cosmetic procedures.[3] Hands-on experience in all procedures must be done under the supervision of an experienced consultant.[3]

We assessed the current status of surgical dermatology training in all SCFHS-accredited programs in Saudi Arabia.


  Methods Top


Survey methodology and target population

In all five SCFHS accredited dermatology residency programs, each residency program director was contacted by e-mail and/or phone to confirm the total number of 4th-year residents and to obtain their e-mail addresses. A total of 29 4th-year residents were enrolled in the program in 2020. A close-ended questionnaire was developed, and a pilot study was conducted for validation to meet the objectives of the study. The survey was approved by the King Saud University Institutional Review Board (No. E-20-5311, November 12, 2020). It was an electronic, anonymous, English questionnaire distributed to all 4th-year residents in all five SCFHS-accredited dermatology residency programs. The questionnaire included an introduction to clarify its voluntary nature and goals and was sent to all 29 residents, through their direct e-mail in December 2020. The e-mail included a hyperlink directing the residents to the questionnaire. A second follow-up e-mail was sent to all nonresponders 3 weeks later to stimulate their reply.

Survey content

The questions of the survey addressed as follows: (1) residents demographic characteristics; (2) the existence of a Mohs surgeon in the program, (3) didactic education in dermatologic surgery; (4) residents' role in different dermatologic surgery procedures; (5) residents' self-perceptions of dermatologic surgery training; and (6) residents' overall satisfaction with their dermatologic surgery training.

Participants' education in surgical dermatology was assessed through the frequency of attending lectures and journal club meetings. Residents were asked about the average number of hours spent in attending or performing surgical procedures during the 4 years of residency and the presence of hands-on or live teaching demonstrations for several procedures. To assess the role of residents in performing laser and various dermatological surgical procedures, the items “no exposure, observer only, assistant, and primary surgeon” were used. Participants viewed their self-perceptions toward the practiced dermatologic surgery procedures through the terms “competent as the primary surgeon,” “experienced in the technique,” or “knowledgeable through lectures and observation.” A Likert scale was used to illustrate the overall resident's satisfaction toward their training in surgical dermatology.

Analysis

Statistical software SPSS is version 22 (Microsoft Windows platform, US) was used to analyze responses. Frequency distribution analysis was performed. Significance of the differences in the results of different groups was obtained using the Chi-square test. A P ≤ 0.05 was considered statistically significant.


  Results Top


A total of 26 4th-year residents participated in the current study, with a response rate of 89.6%. More than half of them were female at 57.7%, and 69.2% of the participants existed equally in the central and western regions [34.6% each, [Table 1]]. About half (53.8%) of the respondents reported the absence of a Mohs surgeon consultant in their program.
Table 1: Dermatology residency program characteristics

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Scope of didactic education

The vast majority of the participants, 96.2%, reported that they have surgical journal club meetings <4 times/year, and 73.1% reported having dermatologic surgical lectures <4 times/year. The procedure with the highest frequency of hands-on or live teaching demonstration was botulinum toxin injections (69.2) and the least was hair transplant (7.7%). Laser and excisional surgery have the highest percentage of teaching with 96.2% and 73.1%, respectively. About 38.5% of the participants reported that they spent only 1–10 h attending or performing dermatologic surgery procedures during the past 4 years of residency [Table 2].
Table 2: Scope of didactic education

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Residents role in laser and dermatologic surgery procedure

In regard to participants' role in laser procedures, 30.8% of residents were assigned as assistants mainly in vascular laser procedures, and 26.9% assisted in laser treatment for pigmented lesions, tattoo removal, and acne scars. On the other hand, 53.8% of the participants were equally assigned as the primary surgeons in laser for acne scar treatment and botulinum toxin for hyperhidrosis. In contrast, the majority of residents reported higher levels of nonexposure for hair transplant procedures at 88.5%, fat transfer at 84.6%, fillers injection, and chemical peels at 65.4% for each [Table 3].
Table 3: Residents role in laser and dermatologic surgery procedure

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Residents' self-perceptions of dermatologic surgery training

When the residents were asked about their perceptions toward dermatologic surgery, 53.8% reported that they see themselves as competent as the primary surgeon in vascular laser and laser for acne scar treatment, while 42.3% reported that they are just experienced in the botulinum toxin technique [Table 4]. Regarding Mohs surgery, 73.1% of them are only knowledgeable about it through lectures and observations, without any hands-on training.
Table 4: Resident expectation of dermatologic surgery training

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The results of the current study revealed no statistically significant differences between the five residency programs in all four regions in our country (central, eastern, southern, and western) in terms of the level of didactic education, resident role in dermatologic surgery training, and their self-perception toward the training in such subspecialty (all P > 0.05). This included – and not limited to – excisional surgery, Mohs surgery, nail surgery, melanocyte transfer, pigmented laser, tattoo removal laser, vascular laser, laser acne scar treatment, ablative resurfacing laser, filler injection, liposuction [Table 5]. Similar results were obtained when the residents were asked about the presence of Mohs surgeon consultant in their program. The association between the presence of Mohs surgeon in the residency program and the residents' perceptions toward their dermatological surgery training did not show any significant difference.
Table 5: Self-assessed surgical competency by program characteristics

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Future plans and level of satisfaction

After dermatology training, the posttraining plans for the residents were 46.2% plan to practice in governmental and private centers, 23.1 plan to join a dermatologic surgery fellowship, 19.2% plan to practice only in a governmental center, and only 7.7% plan to practice in a private center. The vast majority of the residents (92.3%) were not satisfied with their training in dermatologic surgery during their 4 years of residency, and none of them were very satisfied.


  Discussion Top


The first report about dermatology residency training in our country was done in 2008.[2] Our report evaluated the dermatologic surgery training in all SCFHS-accredited dermatology residency programs in Saudi Arabia. The response was high (89.6% response rate), facilitating an accurate description. While the limited number of participants (26 residents) limits statistical inferences, the data provide a clear, general picture of Saudi dermatology residents' surgical training and identified weakness in areas including surgical journal club meetings, dedicated lecturers, and hands-on-or live teaching demonstrations during the 4 years of residency.

The scarcity of comparable recent studies assessing training and exposure to such subspecialty in dermatology residency programs (particularly, the local ones) makes comparing our results difficult. Data from a previous study conducted almost two decades ago in Pennsylvania showed that 55% of the programs offered some liposuction training to their residents.[4] This is in addition to 45% and 63% for hair transplantation and fillers injections, respectively. In the present study, only 19.2% of the residents have hands-on or live teaching demonstration for fillers injection and 7.7% for hair transplant. Such findings highlight the low training levels in the dermatologic surgery residency programs in Saudi Arabia. Residents should become familiar with hair transplantation, laser resurfacing, liposuction, tissue augmentation, chemical peel, and others. Besides, residents should have experience with Mohs microscopic surgery. Most residency programs are providing exposure to cosmetic procedures.[4],[5] Todd et al.[4] showed that 92% of the residency programs offered Mohs microscopic surgery, while in this study, only 19.2% have a hands-on or live teaching demonstration for Mohs surgery. Most residency programs are providing exposure to cosmetic procedures.[4],[5] However, the present study results some movement in the right direction when compared to a locally published study in 2008 in which none of the residents reported performing liposuction or filler injection.[2] Besides, only 10% of residents participated as assistants in Mohs surgery, while in the current study, 19.2% reported having hands-on or live teaching on Mohs surgery.

Several previous international studies reported that dermatology residents felt that they were not trained sufficiently in cosmetic dermatology and that they would favor more training time in this area.[6],[7],[8] Our study has the similar finding, where 92.3% of the residents were not satisfied with their training in dermatologic surgery procedures, strongly suggesting the need for more training in this field.

In clinical practice, despite the large current demand toward performing cosmetic procedures, this area of dermatology, before two decades, was considered to be unimportant by some residency programs.[9] Moreover, there is an expression of concern that, spending more time in training residents in cosmetics, makes residents' training in medical dermatology compromised and might result in residents having less interest and expertise in medical dermatology.[10]

Group et al.[11] reported that exposure to assigned readings and didactic lectures were the principles of cosmetic dermatology for most residents, while in the present study, most of the residents reported that their exposure to such lectures was less than four times a year. When we evaluated the types of cosmetic procedures with which residents have hands-on or live teaching demonstration, laser surgery and botulinum toxin injections were the most common. Previous studies[10],[11] found that the most commonly performed cosmetic procedures by residents are injections of botulinum toxin, fillers, and sclerotherapy.

The presence of significant differences between aesthetic and medical dermatology training has been reported in the. In the United States, 94% to 100% of dermatology programs provided botulinum toxin training, with 95% of residents being able to practice performing the procedure.[12],[13] In contrast, only 18.6% of Canadian organizations provided hands-on training with botulinum toxin injections.[12],[13] Although Canadians undergo fewer hands-on aesthetic dermatology instructions than Americans, the amount of didactic lecture time is equivalent, ranging from 1 to 10 h.[14] In the present study, 69.2% of the participated residents reported having hands-on or live teaching for botulinum toxin.

Saudi dermatology residents express and high level of dissatisfaction with their surgical training experience; the experience is somewhat better than it was a decade ago.[2] There is much to learn in dermatology, and it is challenging to find an appropriate balance between medical dermatology, dermatopathology, and dermatologic surgery training during the 4 years of residency. We hope that data from the current study would be valuable and assist planners of the programs for revising, structuring, or restructuring their residency curricula to match the growing demand for dermatologic surgery and cosmetic dermatology procedures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Reichel JL, Peirson RP, Berg D. Teaching and evaluation of surgical skills in dermatology: Results of a survey. Arch Dermatol 2004;140:1365-9.  Back to cited text no. 1
    
2.
AlGhamdi KM. Current status of dermatology residency training in Saudi Arabia: Trainees' perspectives. East Mediterr Health J 2008;14:1185-91.  Back to cited text no. 2
    
3.
Saudi Commision for Health Specialities (SCFHS). Training, Postgraduate Programs, Dermatology, Program Brochure; 2016. Available from: http://www.scfhs.org.sa. [Last accessed on 2021 Apr 29].  Back to cited text no. 3
    
4.
Todd MM, Miller JJ, Ammirati CT. Dermatologic surgery training in residency. Dermatol Surg 2002;28:547-9.  Back to cited text no. 4
    
5.
Neville JA, Housman TS, Letsinger JA, Fleischer AB Jr., Feldman SR, Williford PM. Increase in procedures performed at dermatology office visits from 1995 to 2001. Dermatol Surg 2005;31:160-2.  Back to cited text no. 5
    
6.
Freeman SR, Greene RE, Kimball AB, Freiman A, Barzilai DA, Muller S, et al. US dermatology residents' satisfaction with training and mentoring: Survey results from the 2005 and 2006 Las Vegas Dermatology Seminars. Arch Dermatol 2008;144:896-900.  Back to cited text no. 6
    
7.
Freiman A, Barzilai DA, Barankin B, Natsheh A, Shear NH. National appraisal of dermatology residency training: A Canadian study. Arch Dermatol 2005;141:1100-4.  Back to cited text no. 7
    
8.
Reid DC, Kimball AB, Ehrlich A. Medical versus surgical dermatology: How much training do residents receive? Dermatol Surg 2006;32:597.  Back to cited text no. 8
    
9.
Coleman WP 3rd, Hanke CW, Orentreich N, Kurtin SB, Brody H, Bennett R. A history of dermatologic surgery in the United States. Dermatol Surg 2000;26:5-11.  Back to cited text no. 9
    
10.
Schleichert R, Hostetler SG, Zirwas M. The perceived influence of cosmetic dermatology on dermatology resident education. J Am Acad Dermatol 2010;63:352-3.  Back to cited text no. 10
    
11.
Group A, Philips R, Kelly E. Cosmetic dermatology training in residency: Results of a survey from the residents' perspective. Dermatol Surg 2012;38:1975-80.  Back to cited text no. 11
    
12.
Kirby JS, Adgerson CN, Anderson BE. A survey of dermatology resident education in cosmetic procedures. J Am Acad Dermatol 2013;68:e23-8.  Back to cited text no. 12
    
13.
Bauer B, Williams E, Stratman EJ. Cosmetic dermatologic surgical training in US dermatology residency programs: Identifying and overcoming barriers. JAMA Dermatol 2014;150:125-9.  Back to cited text no. 13
    
14.
Worley B, Verma L, Macdonald J. Aesthetic dermatologic surgery Training in Canadian residency programs. J Cutan Med Surg 2019;23:164-73.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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