Dermatology Online Journal

The "away" dermatology elective for visiting medical students: Educational opportunities and barriers
Rebecca C Philips¹, Navin Dhingra¹, Tatsuo Uchida MS², Richard F Wagner Jr MD¹
Dermatology Online Journal 15 (10): 1

1. The Department of Dermatology
2. The Office of Biostatistics
The University of Texas Medical Branch, Galveston, Texas. rfwagner@utmb.edu

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Abstract

Dermatology electives allow medical students an opportunity to explore the field of dermatology. In order to gain greater exposure to the specialty of dermatology, some medical students have an interest in taking "away" dermatology electives at other U.S. medical schools. A telephone survey was conducted to better understand the opportunities and barriers that exist for visiting medical students to take an elective in dermatology. Areas of focus in the survey included dermatology elective offerings, institutional policies toward visiting students, academic requirements for visiting students, timing of electives, financial costs of electives incurred by the student and institutional and regional preferences of the host medical school. Survey results indicated considerable opportunities for medical students to explore the field of dermatology among U.S. medical schools, but variance among schools regarding the number and types of dermatology electives offered. Medical schools with dermatology residencies were statistically more likely to offer dermatology electives to visiting medical students than those that did not (p<0.0001). Students from schools that do not provide more advanced electives may find it difficult to explore the field beyond a general dermatology elective because of the limited availability of subspecialty elective rotations for visiting students. Other barriers for "away" electives include academic requirements, priority in course registration for a school's own students, differing rotation schedules, and additional financial costs.

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Introduction

Opportunities for upper level medical students to gain exposure in dermatology vary considerably among U.S. medical schools. Some medical schools do not offer any dermatology electives to their students whereas other medical schools offer a large variety. Medical schools offer different types of electives including basic science research electives, introductory clinical electives, acting internships, and an array of subspecialty electives. Disparity also exists in accessibility for medical students desiring to take dermatology electives at other schools. Institutional policies toward visiting students, a lack of corresponding rotation schedules, additional financial costs incurred by students, and other preferences by the host school can deter a student from pursuing "away" electives.

A telephone survey was conducted with all U.S. medical schools accredited by the Liaison Committee on Medical Education (LCME) in order to better understand the opportunities and barriers that exist for medical students to take away electives in dermatology.

Methods

Figure 1

An Institutional Review Board exempt telephone survey (Figure 1) was conducted with registrar, curriculum, student affairs and dermatology department offices at 130 U.S. LCME accredited medical schools in June and July of 2009. Four of the 130 schools had LCME preliminary accreditation status. The Association of American Medical Colleges (AAMC) Online Extramural Electives Compendium and the AAMC Visiting Student Application Service were used to identify contact information for the schools. A student electives coordinator, a visiting student coordinator or a dermatology department coordinator completed most surveys. Frequently more than one person at a school was required to answer all of the questions. Occasionally an exploration of online course catalogs and visiting student requirements published by the school was used to complete the survey if requested by the person responding. Survey responders were given the option to return the survey by email if responding by telephone was inconvenient. Schools failing to respond after at least three telephone calls and an email were excluded from the study.

Existence of residency program and acceptance of visiting students were assessed using the Pearson chi-square test for their association. The chi-square test was carried out using PROC FREQ in the SAS® system, release 9.1 [1] and assessed at the 0.05 level of significance.

Results

Survey Population

Ninety-eight of the 130 LCME-accredited U.S. allopathic medical schools responded to the survey. Two schools, the University of Texas Medical Branch at Galveston and the University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School, noted a second campus with a separate dermatology residency program and additional electives for medical students. Therefore, a total of 100 of 132 schools (75.8%) were interviewed. Participating schools were located in 40 of the 44 (90.9%) states with at least one medical school, in addition to the District of Columbia and Puerto Rico (Table 1).

How many U.S. medical schools accept visiting medical students for dermatology electives?

Seventy-seven of the 100 (77%) participating U.S. medical schools accept visiting allopathic medical students for dermatology electives. Sixty-five (65%) schools accept visiting osteopathic medical students and one school could not determine if osteopathic medical students are accepted. Forty (40%) schools accept students from international medical schools. Two schools accepting allopathic medical students, 4 schools accepting osteopathic medical students and 9 schools accepting international medical students provided specific restrictions for applicants. Restrictions include regional, affiliation, established exchange agreement and faculty sponsor requirements (Table 2 and Table 3).

What electives in dermatology do U.S. medical schools offer to their own students?

Thirteen (13%) of the 100 participating U.S. medical schools do not offer dermatology electives in their curriculums. Thirty-four schools (34%) offer only one dermatology elective to their own students; 20 schools (20%) offer two electives; 18 schools (18%) offer three electives; 11 schools (11%) offer four electives; 4 schools (4%) offer five or more electives.

Of the 87 schools that offer dermatology to their own students, 86 schools (98.9%) offer an introductory clinical dermatology elective; however, 36 schools (41.4%) offer only introductory clinical dermatology and no additional electives. The specific titles of introductory clinical electives vary and include "General Dermatology," "Off Campus Clerkship," "Dermatology Clinic," "Dermatology Preceptorship," among other titles. Of the 87 schools that offer dermatology to their own students, 36 schools (41.4%) offer a research elective. Thirty-one schools (35.6%) offer at least one subspecialty elective to their own students. Specifically, 8 schools (9.2%) offer dermatologic surgery, 21 schools (24.1%) offer dermatopathology, 9 schools (10.3%) offer pediatric dermatology, and Mt. Sinai School of Medicine (1.1%) offers cosmetic dermatology. Three schools (3.4%) offer a dermatology acting internship to their own students.

Do U.S. medical schools accepting visiting medical students for dermatology electives have a dermatology residency program?

Of the 100 participating U.S. medical schools, 66 schools (66%) have a dermatology residency program at their institution. We observed a significant association (p<0.0001) between existence of a residency program and the acceptance of visiting students (Table 4). Those schools that have residency program most likely (95.5%, 63/66) accept visiting students. On the other hand, those schools that do not have a residency program tend not to accept visiting students (58.8%, 20/34).

What electives in dermatology do U.S. medical schools offer to visiting medical students?

Of the 77 participating U.S. medical schools that accept visiting medical students for dermatology electives, 36 schools (46.8%) offer one elective to visiting medical students; 22 schools (28.6%) offer two electives; 11 schools (14.3%) offer three electives; 4 schools (5.2%) offer four electives; 4 schools (5.2%) offer five or more electives (Table 5). Seventy-six schools (98.7%) offer an introductory clinical elective to visiting students; however, 36 schools (46.8%) offer only introductory clinical dermatology and no additional electives. Twenty-three schools (29.9%) offer a research elective to visiting students (Table 6). Twenty-seven schools (35.1%) offer at least one subspecialty elective to visiting students: 5 schools (6.5%) offer dermatologic surgery (Table 7), 19 schools (24.7%) offer dermatopathology (Table 8), 8 schools (10.4%) offer pediatric dermatology (Table 9) and only Mt. Sinai School of Medicine (1.3%) offers cosmetic dermatology. Two schools (2.6%) offer an acting internship to visiting students. Additional electives offered to visiting students cover a wide range of topics, including Wound Healing, HIV, Cancer Dermatology, Skin Diseases in Modern World Literature, History of Dermatology, Skin Disease Depicted in Film, and Phototherapy and Psoriasis.

Sixty schools (77.9%) offer all dermatology electives in their curriculum to visiting students. Seven schools (9.1%) do not allow visiting students to take one type of introductory clinical dermatology elective; however, all of these schools offer at least one type of introductory clinical dermatology elective that visiting students are allowed to take. Introductory clinical electives not available to visiting students include off-site electives or electives with an unusual schedule on nonconsecutive days. Eight schools (10.4%) do not allow visiting students to take the dermatology research elective. Two schools (2.6%) do not allow visiting students to take one of the offered subspecialty electives. Several schools additionally restrict enrollment of special electives, such as Dermatology Honors Program, Advanced Dermatology, and Sun Protection Outreach Teaching, to their own students.

How is the number of positions available per elective for visiting students determined?

Of the 77 participating U.S. medical schools accepting visiting medical students for dermatology electives, 5 schools (6.5%) reserve 1 to 3 positions per elective for visiting students. Four of the 5 schools (80%) that reserve positions for visiting students allow visiting students to fill additional positions if space is available after their own students have registered for the elective. Two schools (2.6%) allow visiting students to fill the maximum number of positions available per elective without priority for their own students in course registration. Seventy schools (90.9%) allow visiting students to fill elective positions only on a space-available basis, after registration for their own students has been completed. Most of the 70 schools theoretically allow visiting students to fill the maximum number of positions available if there is space available. However two schools specify that there is a limit on the number of positions available for visiting students even if space is available.

What are the academic requirements for visiting medical students?

Of the 77 participating U.S. medical schools accepting visiting medical students for dermatology electives, 69 schools (89.6%) require visiting medical students to be in their 4th year prior to taking dermatology electives and 70 schools (90.9%) require visiting medical students to have completed their core clerkship requirements. Three of the schools requiring visiting students to complete their core clerkship requirements and be in their 4th year prior to taking a dermatology elective stated that they will occasionally make exceptions to this rule. Of the 30 schools that offer a subspecialty or more advanced elective to visiting medical students, 23 schools (76.7%) do not require introductory clinical dermatology as a prerequisite. The remaining 7 schools (23.3%) require introductory clinical dermatology as a prerequisite to at least one if not all subspecialty or more advanced electives.

Fifty-six schools (72.7%) stated that the academic requirements for visiting students were identical to those of their own students. The remaining schools differed in that their own students could take at least one if not all dermatology electives during the 3rd year, while visiting students could only take the electives during the 4th year.

The majority of participating U.S. medical schools accepting visiting osteopathic medical students did not have additional academic requirements for osteopathic visiting students compared to allopathic visiting students. Six of 65 schools (9.2%) require osteopathic students to provide proof of a passing score on either the USMLE or COMLEX exam. One school requires osteopathic students to be in the last half of their 4th year to participate in electives.

What is the timing of dermatology electives for visiting medical students?

Most participating U.S medical schools accepting visiting medical students offer dermatology electives of a duration that is a factor of 2 weeks: 4 schools (5.2%) offer all 2-week electives, 52 schools (67.5%) offer all 4-week electives and 17 schools (22.1%) offer combinations of 2, 4, 6 or 8-week electives. Three schools (3.9%) specified a one-month elective duration. One school offers electives of 3-week duration.

Visiting students are limited by the number of total weeks they can spend taking electives at 74 of the 77 (96.1%) participating U.S. medical schools accepting visiting medical students: 8 schools (10.4%) set a 4-week limit; 39 schools (50.6%) set an 8-week limit; 22 schools (28.6%) set a 12-week limit; 3 schools (3.9%) set a 16-week limit; 1 school (1.3%) sets a 3-month limit; 1 school (1.3%) sets a 4-month limit.

The number of months out of a single year that dermatology electives are available to visiting students provides another limitation. Thirty-three schools (42.9%) offer dermatology electives to visiting students during twelve months of the year; 15 schools (19.5%) offer electives during eleven months; 16 schools (20.8%) offer electives during ten months; 5 schools (6.5%) offer electives during nine months; 5 schools (6.5%) offer electives during eight or fewer months. Two schools offered electives during a variable number of months based on the type of elective and one school was unable to provide a response.

2009 rotation start dates for 4th year students at the 77 participating U.S. medical schools accepting visiting medical students range from January 5, 2009 to August 17, 2009. The majority of schools had a 4th year rotation start date on June 29, 2009 (9 schools, 11.7%) or July 6, 2009 (40 schools, 51.9%). Thirty-eight schools (49.4%) stated that visiting students are not allowed to join an elective late, even if necessitated by a different rotation schedule at their home institution. One school (1.3%) will allow visiting students to join electives 1 to 2 days late. Six schools (7.8%) will allow visiting students to join electives by the end of the first week. Twenty-nine schools (37.7%) try to accommodate the visiting student's rotation schedule. Three schools (3.9%) will occasionally allow students to join late, making the decision on a case-by-case basis or depending on the specific elective.

What is the financial cost of a dermatology elective for visiting medical students?

Application fees, tuition and malpractice coverage are potential sources of additional financial cost for visiting medical students. For the 77 participating schools accepting visiting medical students, application fees range from no fee (28 schools, 36.4%) to $150 per application (4 schools, 5.2%). Thirty-six schools (46.8%) require application fees between $50 and $125. Only 5 schools (6.5%) require tuition: 2 schools require $25 per elective; 1 school requires $50 per elective; 1 school requires $200 total; 1 school requires $500/elective. The majority of schools (76 schools, 98.7%) require visiting students to have malpractice coverage. However, 12 schools (15.6%) do not require a minimum malpractice coverage premium and either provide coverage for the visiting student or accept the amount of malpractice coverage provided by their home institution (Table 10). Of the 64 schools that require visiting students to purchase malpractice coverage, 9 schools (14.1%) charge $2 to $50 for the required additional insurance (Table 11). The remaining 55 schools require visiting students to purchase malpractice coverage independently and vary in the amount of minimum single occurrence and minimum aggregate malpractice coverage needed. Two of the 55 schools (3.6%) requiring independent purchase of malpractice coverage require a minimum single occurrence in the $0-49,999 range; 1 school (1.8%) in the $50,000-249,999 range; 2 schools (3.6%) in the $250,000-499,999 range; 1 school (1.8%) in the $500,000-999,999 range; 47 schools (85.5%) in the $1,000,000 or more range. Two schools were unable to respond regarding the malpractice coverage required (Table 12). In addition to financial cost, student time and effort to coordinate insurance coverage with an independent company may be daunting.

Is short-term housing available for visiting medical students?

Seventeen schools (22.1%) provide student housing for visiting medical students. However, some schools indicated limited housing availability. Of the 59 schools that do not provide student housing, 42 schools (71.2%) provide assistance in locating housing, most frequently in the form of a list of local short-term housing options. One school was unable to respond to the question.

Is priority in registration given to visiting medical students based on residential preferences?

Of the 63 participating U.S. medical schools that accept visiting medical students and are located in a state with more than one medical school, 5 schools (7.9%) give priority in course registration to students attending a school in the same state. Of the 40 participating U.S. medical schools that accept visiting students from international medical schools, 10 schools (25%) give priority in course registration to students attending a school in the U.S., 23 schools (57.5%) do not give priority to U.S. medical students and the remaining schools were unable to respond.

What is the ease in applying for an away dermatology elective?

Of the 77 participating U.S. medical schools accepting visiting medical students for dermatology electives, 44 schools (57.1%) currently participate in the electronic Visiting Student Application Service (VSAS), a program of the Association of American Medical Colleges. Five schools specified additional materials that are required with the application, including a medical school transcript, curriculum vitae, statement of residency intent, letter of recommendation from the student's home institution department of dermatology, and a personal statement. It is possible that more schools require these items, but did not specify in the survey. The application due date varies considerably among schools and ranges from having no due date to requiring the application at least 90 days before the start of the elective.

Discussion

Dermatology residency positions remain highly competitive in the United States. The availability of "away" electives in dermatology appears to be an important factor in a successful dermatology residency match for some applicants. In one survey 53 percent of successful applicants matched either at their home program or at a program where they took an away dermatology rotation [2]. Dermatology away electives are also a valuable tool for students to explore the field of dermatology. Elective offerings vary greatly among U.S. medical schools. An introduction to the field of dermatology is readily available at most U.S. medical schools. However, a more in depth exposure to dermatology through research and subspecialty electives, such as dermatopathology, dermatologic surgery, and pediatric dermatology, is more limited. Nearly half of U.S. medical schools either offer no electives in dermatology or only an introductory clinical dermatology elective to their own students. Students at these schools may find it difficult to explore dermatology and could greatly benefit from the availability of away elective experiences.

Considerable opportunity exists for allopathic medical students to take away electives in dermatology. Seventy-seven percent of U.S. medical schools accept visiting allopathic students for dermatology electives and the majority of these schools offer all dermatology electives in their curriculum to visiting students. Opportunities to take away electives in dermatology are more limited for osteopathic and international medical students. Sixty-five percent of participating U.S. medical schools accept osteopathic medical students for dermatology electives. A substantial barrier exists for international medical students because only 40 percent of U.S. medical schools accept international students, and in addition, may require a faculty sponsor or academic affiliation.

A number of factors, including academic requirements, priorities in course registration, elective schedules and financial costs, may create barriers for visiting students and reduce the feasibility of taking an away elective in dermatology. Most schools require visiting students to complete their core clerkship requirements and be in their 4th year prior to taking an away elective in dermatology. In addition, visiting students face the combination of limited positions in dermatology electives, high demand from the schools' own students, and a lower priority than many schools afford their own students in registration. Differing rotation schedules may create a barrier to scheduling away dermatology electives. In 2009, there was a 51.9 percent starting date concordance for 4th year rotations. However, nearly half of the schools do not allow visiting students to join an elective late, effectively diminishing student ability to take away electives if their own school is on a different rotation schedule. Non-uniform malpractice coverage requirements may also limit medical student participation in away electives. Most schools provide their students with a level of coverage that enables them to pursue electives freely, but visiting students from medical schools that do not provide adequate insurance may have difficulty finding coverage or the additional cost may be prohibitive.

The barriers to visiting student participation in dermatology away electives should be addressed to create more opportunities for medical students to gain exposure to the specialty of dermatology and potential residency programs. The creation of additional exchange programs with international schools and less restriction for visiting osteopathic students would help facilitate away dermatology rotations for these students. Schools with electives that are in high demand could reserve one position during some rotation periods for visiting students who show special interest in their dermatology program. Institution of uniform national starting dates for electives during the senior year of medical school would help to reduce scheduling conflicts for visiting students in their 4th year. To resolve obstacles created by the need for additional malpractice coverage, schools that provide their students with lower coverage levels could proactively address their students' need for access to additional coverage during away rotations. Additionally, more medical schools with higher malpractice premium requirements could provide a pathway for visiting students to purchase the additional required coverage.

Conclusion

Considerable opportunities exist for visiting medical students pursuing away electives in dermatology. However, barriers such as strict academic requirements, priorities in course registration for a school's own students, differing rotation schedules and the financial costs of malpractice coverage may limit away elective feasibility. Current limitations on visiting student participation in away electives should be addressed to enhance medical student exposure to the field of dermatology and potential residency programs.

References

1. SAS Institute Inc., SAS/STAT ® 9.1 User's Guide, Cary, NC; SAS Institute Inc., 2004.

2. Clark JT, Miller JJ, Sceppa J, et al. Success in the dermatology residency match in 2003: perceptions and importance of home institutions and away rotations. Arch Dermatol 2006; 142: 930-932.

© 2009 Dermatology Online Journal