Letters to the Editor: October 2024

J Clin Aesthet Dermatol. 2024;17(10):17–18.

An Innovative Antidote to Burnout

Dear Editor:

Burnout rates among US physicians have hovered around 50 percent since they were initially measured in 2011, with an increase during the COVID-19 pandemic and the most recent (2021) data reporting that 62.8 percent of surveyed physicians had at least one symptom.¹ In this environment threatening the future of medicine, we propose an antidote directly targeting a common cause of burnout in academic dermatologists (identified by Dorrell et al): lack of protected time for pursuing academic interests such as research or teaching.² Recognizing that traditional funding for medical research is limited, we propose that the antidote to burnout must leverage the unique training and perspective of physicians to innovatively improve patients’ health and bring value to the medical system. Physicians have an intimate knowledge of patients’ problems which is nearly impossible to replicate. However, they need to learn how to bridge the gap between recognizing an important clinical problem and creating a sustainable and innovative solution. 

The Magic Wand Initiative (MWI) is a creative educational program launched at Massachusetts General Hospital by-clinicians-for-clinicians to increase physician engagement in problem-based innovation by their understanding of problems worth solving in dermatology.³ It uses the iterative process of design thinking and applies that to innovation by teaching clinicians how to identify and deeply understand unmet medical needs, brainstorm solutions, and ultimately match themselves with scientists and resources needed to solve these problems. 

In 2017, in an effort to foster faculty creativity, author JJZ created an Entrepreneurs’ Circle (EC) at the University of Utah Department of Dermatology (where he served as chair) and selected author SEZ to lead the group. She discovered the MWI curriculum at the Dermatology Innovation Forum and brought it back to use as a roadmap for Utah’s EC. Using the curriculum, Utah faculty identified and worked to understand problems including patients’ low adherence to topical medication regimens, staff and patient frustration navigating patient calls and ineffective access to dermatologic care for Native American populations. 

Two years into the program, also at a time when universities were furiously searching for ways to reduce physician burnout and recruit and maintain physician-scientists, author JJZ noticed that physicians in the EC seemed happier. With this in mind, we surveyed the 39 clinical faculty at Utah, seven of whom participated in the inaugural EC. Comparing participant to non-participant faculty, while not statistically significant because of small sample size, revealed that those participating in the program felt more empowered to make changes in their daily work environment, were more likely to recommend working in the Department to a physician friend and reported a self-assessed lower degree of burnout and higher degree of career satisfaction.

The heart of the MWI recognizes physicians’ unique perspective in medical care delivery, and promotes physician engagement, which is defined as the opposite of burnout. Evidence suggests that physicians who spend at least 20 percent of their professional effort focused on the dimension of work they find most meaningful are less likely to experience burnout.⁴ We propose that the MWI is a tool for physicians to discover meaningful work in the often foreign arena of innovation and is therefore a powerful antidote to burnout.

Acknowledgments. We would like to thank R. Rox Anderson, who, together with author LG, designed and piloted the Magic Wand program at Wellman Center for Photomedicine and Massachusetts General Hospital (MGH) Department of Dermatology in 2013.

With regard,

Stephanie E. Zone, MD; John J. Zone, MD; and Lilit Garibyan MD, PhD

Keywords Burnout, innovation, academic medicine, faculty engagement, career satisfaction

Affiliations.  Drs. SE Zone and JJ Zone are with the Department of Dermatology at the University of Utah in Salt Lake City, Utah. Dr. Garibyan is with the Wellman Center for Photomedicine at Massachusetts General Hospital and the Department of Dermatology at Harvard Medical School in Boston, Massachusetts. 

Funding. Financial support for the launch of the Magic Wand program was provided by Advancing Innovation in Dermatology (AID), a nonprofit organization committed to fostering innovation in dermatology.

Disclosures. Mass General Hospital (MGH), employer of  Dr. Garibyan, holds the trademark for “Magic Wand Initiative.”

References:

1. Shanafelt TD, West CP, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic. Mayo Clin Proc. 2022.
2. Dorrell DN, Feldman SR, Huang WW. The most common causes of burnout among U.S. academic dermatologists based on a survey study. J Am Acad Dermatol. 2019.
3. Garibyan L, Anderson RR. Increasing clinical faculty engagement in problem-driven research: the “Magic Wand” initiative at Massachusetts General Hospital. JAMA Dermatol. 2017;153(5):375–376.
4. Shanafelt TD, West CP, Sloan JA, et al. Career fit and burnout among academic faculty. Arch Intern Med. 2009;169(10):990–995. 

The Challenges of Managing Psoriasis on the Ear

Dear Editor:

Psoriasis, a common inflammatory skin condition, can affect specific body sites or affect the entire skin surface. Managing certain areas such as the face, genitalia, palms, and soles of the feet poses a particular challenge. Even when psoriasis is limited and localized, with a low Psoriasis Area and Severity Index (PASI), it significantly compromises patients’ quality of life. Consequently, systemic therapy can be necessary and endorsed.¹ However, should we include other anatomical regions in this list of the difficult-to-treat areas? Psoriasis can, not infrequently, affect the ear structures, also as the only localization (Figure 1). It may affect all ear components, from the auricle to the external auditory tract, the middle and inner ear. Itching and/or pain are often severe and distressing. Visible scales can lead to social embarrassment. Some studies indicate that ear psoriasis may even impair auditory function, causing chronic conductive and/or sensorial deafness, even dizziness is possible due to the involvement of cochlea.² In addition, another uncommon complication of ear psoriasis is external otitis, which should be considered also as a possible differential diagnosis beyond seborrheic dermatitis and eczema.³ Thus, while the PASI may not be markedly high, the Dermatology Life Quality and Severity Index (DLQI) is often significantly elevated. 

The therapeutic approach for ear psoriasis can be tricky. Topical ointments or foam are often poorly tolerated, leading to reduced treatment adherence.⁴ The chronic nature of the condition requires frequent applications, with potential local side effects such as skin atrophy and infections. In these cases, a systemic approach should be considered, despite the limited extent of the disease. Systemic treatments encompass both traditional agents like methotrexate and cyclosporine, as well as innovative drugs, including small molecules and monoclonal antibodies. Among the latter, interleukin (IL)-17 and IL-23 antagonists are particularly promising. In conclusion, psoriasis localized in the ear remains a neglected area in current medical understanding. Despite its limited spread, it significantly impacts quality of life. In certain conditions, PASI is not a complete and reliable scoring tool, instead DLQI should have a greater importance. We suggest that severe psoriasis involving the ear can be an indication for systemic therapies. Moreover, specific rating score should be employed. For example, a Physician Global Assessment (PGA), specific for the genitalia already exist. We propose that specific PGA also for ear psoriasis should be available. Other issues deal with the difficulty to visualize the inner ear structures; thus, the cooperation of other specialists becomes important. Eventually, more studies are imperative to correctly score ear psoriasis, evaluate possible hear problems and to assess the efficacy, safety, and tolerability of systemic treatments in addressing this specific type of psoriasis.

With regard,

Gaetano Licata, MD; Vittorio Tancredi, MD; Giorgia Giuffrida, MD; Nicoletta Bernardini, MD; Leonardo Zichichi, MD, and Elena Campione, MD

Keywords. Ear psoriasis, biologics, difficult-to-treat areas

Affiliations.  Drs. Licata and Zichichi are with the Dermatology Unit at San Antonio Abate Hospital in Trapani, Italy. Dr. Tancredi is with the Dermatology Unit, Department of Mentals and Physical Health and Preventive Medicine at the University of Campania Luigi Vanvitelli in Naples, Italy. Dr. Giuffrida is with Unità Operativa Dermatologia, Ospedale San Marco in Catania, Italy. Dr. Bernardini is with the Department of Medico-Surgical Sciences and Biotechnologies, Polo Pontino at Sapienza University of Rome, in Rome, Italy. Dr. Campione is with the Department of Dermatology at the University of Roma Tor Vergata in Rome, Italy.

Funding. No funding was provided for this article.

Disclosures. The author reports no conflicts of interest relevant to the content of this article.

References:

1. Nicolescu AC, Ionescu MA, Constantin MM, et al. Psoriasis management challenges regarding difficult-to-treat areas: therapeutic decision and effectiveness. Life (Basel). 2022;12(12):2050.
2. Jeong SS, Shih MC, Rizk HG, et al. Otologic manifestations of psoriasis: a systematic review and meta-analysis. Otol Neurotol. 2022;43(7):742–752.
3. Hajioff D, MacKeith S. Otitis externa. BMJ Clin Evid. 2015;2015:0510.
4. Nasimi M, Abedini R, Ghandi N, et al. Topical treatment adherence and associated factors in patients with psoriasis: A single center, cross-sectional study. Dermatol Ther. 2022 Jul;35(7):e15547.