The Origin of Dermatopathology and Dermatopathologists

The study of histology of the skin has a long documented history dating back to the 1600s. Discoveries first came from European physicians, with contributions since made by numerous notable pathologists and dermatologists from around the world. In 1792, Henry Seguin Jackson of London, England coined the term “dermatopathology” and in 1844 the German Julius Rosenbaum the term “dermatopathologists.” Formalized training in DP in the United States began in 1950 with the creation of the Osborne Fellowship at the Armed Forces Institute of Pathology (AFIP) directed by Dr Elson Helwig.

The American Society of Dermatopathology and Board Certification in Dermatopathology

In 1963, the American Society of Dermatopathology (ASDP) was established. The idea for this new society composed of pathologists and dermatologists came from the dermatopathologist Dr John Haserick of the Cleveland Clinic. In 1970, the ASDP approved a resolution to submit to their member boards (the American Board of Dermatology [ABD] and the American Board of Pathology [ABP]) a request for Subspecialization in Dermatopathology. Over the next 3 years negotiations between the ABD and the ABP continued, and in 1973 they agreed to a joint subspecialty certifying examination in DP, which was subsequently approved by the American Board of Medical Specialties (ABMS). The first DP certifying examination was held in 1974 in Washington, DC. Initially, one was not required to have completed a DP fellowship to take the certifying examination. However, beginning in 1982, eligibility to take the DP certifying examination included the requirements that one must have completed an accredited graduate medical education (GME) program in dermatology or pathology residency, and DP fellowship of at least 1 year’s duration.

The Practice of Dermatopathology

Maintaining subspecialty certification in DP is predicated on continued board certification in dermatology or pathology. In Europe and around the world, the practice of DP varies greatly between countries, between institutions, and even within a single institution. For example, in Germany both dermatologists and pathologists evaluate skin biopsies, whereas in Italy only pathologists are allowed to perform this specialized skill except in some academic institutions where dermatologists may also interpret skin biopsies. In the United States, pathologists and dermatologists may interpret skin biopsies. In early American DP, individual medical specialty boards were responsible for certifying that a physician was qualified to practice their specialty. Today, residency and fellowship programs in the United States are accredited by the larger organization, the Accreditation Council for Graduate Medical Education (ACGME).

Accreditation Council for Graduate Medical Education and Dermatopathology Education

In 1981, the ACGME was created by the joint effort of the American Medical Association (AMA), the ABMS, the American Hospital Association (AHA), the Association of American Medical Colleges (AAMC), and the Council of Medical Specialty Societies (CMSS) because of a consensus within the medical community of the need for an independent accrediting organization for GME. Today, the ACGME is the sole organization that accredits educational programs for the medical profession.

In 1999, the ACGME broadened the scope of medical education from its primary focus of imparting medical knowledge when they endorsed the 6 core competencies (patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice). The ACGME and ABMS provided guidance for suggested best methods for measuring competency in each of these 6 areas. Little guidance was provided with respect to identifying, implementing, or measuring DP-specific core competencies. Specifically, in 2002 the guide to residency curricula and core competencies developed by the Association of Directors of Anatomic and Surgical Pathology excluded subspecialty areas with dedicated fellowships and board examinations (eg, DP). To address the lack of DP-specific core competencies, one publication in 2006 provided some initial, measurable, competency-based objectives for GME programs to be considered when working to meet these ACGME requirements.

The 6 core competencies were developed as part of the ACGME program termed The Outcomes Project. Now the ACGME has created the Milestone Project, and is working with Residency Review Committees (RRCs), specialty medical organizations, and specialty boards to detail specific skill and knowledge sets that residents must achieve by specific time points during training to progress toward mastery of the 6 competencies. Assessing achievement of those objectives and improving the evaluation process are challenging goals and they, like the objectives themselves, are in an evolving process targeted at public assurance of practice competency.

The Origin of Dermatopathology and Dermatopathologists

The study of histology of the skin has a long documented history dating back to the 1600s. Discoveries first came from European physicians, with contributions since made by numerous notable pathologists and dermatologists from around the world. In 1792, Henry Seguin Jackson of London, England coined the term “dermatopathology” and in 1844 the German Julius Rosenbaum the term “dermatopathologists.” Formalized training in DP in the United States began in 1950 with the creation of the Osborne Fellowship at the Armed Forces Institute of Pathology (AFIP) directed by Dr Elson Helwig.

The American Society of Dermatopathology and Board Certification in Dermatopathology

In 1963, the American Society of Dermatopathology (ASDP) was established. The idea for this new society composed of pathologists and dermatologists came from the dermatopathologist Dr John Haserick of the Cleveland Clinic. In 1970, the ASDP approved a resolution to submit to their member boards (the American Board of Dermatology [ABD] and the American Board of Pathology [ABP]) a request for Subspecialization in Dermatopathology. Over the next 3 years negotiations between the ABD and the ABP continued, and in 1973 they agreed to a joint subspecialty certifying examination in DP, which was subsequently approved by the American Board of Medical Specialties (ABMS). The first DP certifying examination was held in 1974 in Washington, DC. Initially, one was not required to have completed a DP fellowship to take the certifying examination. However, beginning in 1982, eligibility to take the DP certifying examination included the requirements that one must have completed an accredited graduate medical education (GME) program in dermatology or pathology residency, and DP fellowship of at least 1 year’s duration.

The Practice of Dermatopathology

Maintaining subspecialty certification in DP is predicated on continued board certification in dermatology or pathology. In Europe and around the world, the practice of DP varies greatly between countries, between institutions, and even within a single institution. For example, in Germany both dermatologists and pathologists evaluate skin biopsies, whereas in Italy only pathologists are allowed to perform this specialized skill except in some academic institutions where dermatologists may also interpret skin biopsies. In the United States, pathologists and dermatologists may interpret skin biopsies. In early American DP, individual medical specialty boards were responsible for certifying that a physician was qualified to practice their specialty. Today, residency and fellowship programs in the United States are accredited by the larger organization, the Accreditation Council for Graduate Medical Education (ACGME).

Accreditation Council for Graduate Medical Education and Dermatopathology Education

In 1981, the ACGME was created by the joint effort of the American Medical Association (AMA), the ABMS, the American Hospital Association (AHA), the Association of American Medical Colleges (AAMC), and the Council of Medical Specialty Societies (CMSS) because of a consensus within the medical community of the need for an independent accrediting organization for GME. Today, the ACGME is the sole organization that accredits educational programs for the medical profession.

In 1999, the ACGME broadened the scope of medical education from its primary focus of imparting medical knowledge when they endorsed the 6 core competencies (patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice). The ACGME and ABMS provided guidance for suggested best methods for measuring competency in each of these 6 areas. Little guidance was provided with respect to identifying, implementing, or measuring DP-specific core competencies. Specifically, in 2002 the guide to residency curricula and core competencies developed by the Association of Directors of Anatomic and Surgical Pathology excluded subspecialty areas with dedicated fellowships and board examinations (eg, DP). To address the lack of DP-specific core competencies, one publication in 2006 provided some initial, measurable, competency-based objectives for GME programs to be considered when working to meet these ACGME requirements.

The 6 core competencies were developed as part of the ACGME program termed The Outcomes Project. Now the ACGME has created the Milestone Project, and is working with Residency Review Committees (RRCs), specialty medical organizations, and specialty boards to detail specific skill and knowledge sets that residents must achieve by specific time points during training to progress toward mastery of the 6 competencies. Assessing achievement of those objectives and improving the evaluation process are challenging goals and they, like the objectives themselves, are in an evolving process targeted at public assurance of practice competency.

Residency Review Committee Requirements

Dermatopathology education is a critical component of a complete medical education for dermatology and pathology residents. The dermatology RRC stipulates that

Residents will examine routinely stained histologic sections from the full spectrum of dermatologic disease. A significant portion of this exposure must occur in an active faculty-run sign-out setting…and training must include education relating to interpretation of direct immunofluorescence specimens, appropriate use and interpretation of immunohistochemistry (special stains, including immunoperoxidase) and electron microscopy.

In the case of pathology, the DP education requirement is that residency programs provide pathology residents with “education in anatomic pathology that must include instruction in autopsy and surgical pathology, cytopathology, pediatric pathology, dermatopathology,” and so forth. The ACGME requires at least semiannual evaluations of residents related to the 6 core competencies, and allows individual residency programs to create their own educational goals, teaching tools, and assessments.

Current Quantity and Components of Dermatopathology Education in Residency

Several studies have surveyed ACGME-approved residencies to document their approaches to DP education. In one study by Singh and colleagues, the investigators surveyed anatomic and clinical pathology (n = 151; 59 responded; 39.1% response rate) as well as dermatology (n = 108; 51 responded; 47.2% response rate) residency programs via email, and asked how many hours of DP education were required of each resident in their program before matriculation (excluding elective time). The results of this study showed that pathology residencies averaged 216.5 hours of DP during a 4-year residency and that dermatology residencies averaged 570.4 hours of DP education during a 3-year residency. In another survey study, investigators used the list serve of the Association of Professors of Dermatology (APD) to query dermatology residency programs as to their DP curriculum (n = 109 residency programs; 52 responded; 48% response rate). Results showed that, on average, 30% of dermatology residency education time was devoted to the study of DP. This substantial amount of time devoted specifically to DP education speaks to the importance each specialty places on DP, particularly given the ever increasing educational demands on residents and residency programs.

When the gross quantity of DP-specific educational sessions is dissected, greater detail is observed as to the relative current use of various DP teaching tools. In the survey study of the APD membership previously mentioned, 38.5% of programs reported having 3 or more weeks of time on the DP service for postgraduate year (PGY)-2 residents, 59.6% for PGY-3 residents, and 69.2% for PGY-4 residents ( Table 1 ). In addition, 40.4% reported using a problem-based learning curriculum, 53.8% reported having a DP journal review, 71.2% have residents review biopsies that they obtain in clinic of whom 65.4% review them with a faculty member, and 19.2% reported using computer-based learning. This graduated experience in DP is the opposite of what some have recommended, including Ackerman.

Table 1

Summary of APD-derived data on DP education in dermatology residencies

Variable		Frequency	Percentage
No. of programs in sample by region	West	5	9.6
	Southwest	0	0
	South	3	5.8
	Midwest	18	34.6
	Northeast	18	34.6
	Southeast	8	15.4
Population size of community	<100,000	8	15.4
	100,000–500,000	8	15.4
	500,001–1,000,000	10	19.2
	>1,000,000	26	50
Programs training at different hospitals	Community hospital	21	40.4
	Veterans hospital	36	69.2
	Student health services	10	19.2
	University hospital and/or clinic	46	88.5
No. of residents	0–3	1	1.9
	4–8	14	26.9
	9–12	20	38.5
	≥13	17	32.7
No. of faculty who teach dermatopathology	1	4	7.7
	2	14	26.9
	3	13	25
	4	5	9.6
	>4	16	30.8
No. of faculty who teach dermatopathology and are board certified in dermatopathology and pathology	0	13	25
	1	15	28.8
	2	16	30.8
	3	2	3.8
	>3	6	11.5
No. of faculty who teach dermatopathology and are board certified in dermatopathology and dermatology	0	5	9.6
	1	16	30.8
	2	15	28.8
	3	7	13.5
	>3	9	17.3
No. of faculty who spend >50% in academic medicine	0	4	7.7
	1	17	32.7
	2	11	21.2
	3	9	17.3
	>3	11	21.2
Nonclinical hours/month for overall resident education	1–10	3	5.8
	11–19	8	15.4
	>19	41	78.8
Nonclinical hours/month for dermatopathology education	1–3	6	11.5
	4–6	20	38.5
	7–9	8	15.4
	10–12	9	17.3
	>12	9	17.3
Weeks in Dermatopathology Rotation by Postgraduate Year (PGY)
PGY 1	0	49	94.2
	1–2	1	1.9
PGY 2	0	25	48.1
	1–2	5	9.6
	3–4	13	25
	>4	7	13.5
PGY 3	0	13	25
	1–2	6	11.5
	3–4	13	25
	>4	18	34.6
PGY 4	0	12	23.1
	1–2	2	3.8
	3–4	18	34.6
	>4	18	34.6
PGY 5	0	49	96.2
	>4	1	1.9
Microscope Time in Hours Led by Each Type of Teacher
By board-certified dermatopathologist	1–2	7	13.5
	3–4	12	23.1
	>4	33	63.5
By board-certified dermatologist	0	41	78.8
	1–2	1	1.9
	3–4	3	5.8
	>4	7	13.5
By board-certified pathologist	0	43	82.7
	1–2	3	5.8
	3–4	1	1.9
	>4	5	9.6
By dermatopathology fellow	0	38	73.1
	1–2	6	11.5
	3–4	4	7.7
	>4	4	7.7
By residents	0	42	80.8
	1–2	4	7.7
	3–4	3	5.8
	>4	3	5.8
Programs using problem-based learning curriculum	Yes	21	40.4
	No	31	59.6
Programs using journal review	Yes	28	53.8
	No	24	46.2
Programs using computer-based learning	Yes	10	19.2
	No	42	80.8
Programs that have residents review their own slides that they obtained from patients in clinic	Yes	37	71.2
	No	15	28.8
If residents review their own slides that they obtained from patients in clinic, do they review the slides with faculty?	Yes	34	65.4
	No	18	34.6
Programs that promote attendance at DP board review program	Yes	15	28.8
	No	37	71.2
Attendance at DP board review program financially supported by residency program	Yes	13	25
	No	39	75
Set of teaching slides available for residents to review	Yes	47	90.4
	No	5	9.6

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