Dermatoethics

This material is intended to serve as a resource for Program Directors and Residents who are looking for a structured curriculum in ethics, and to fulfill ACGME expectations in this realm. 

RECOMMENDED TOPICS FOR 3-YEAR DERMATOETHICS CURRICULAR CYCLE

A. BASIC FOUNDATIONS (C)
* Working definition of ethics
* Defining basic moral philosophy of consequentialism, virtue-based and duty-based moral decision-making
* How to analyze an ethics case

B. PROFESSIONALISM 
* Professional boundaries (C)
* Physician impairment, including physician well-being, burnout, substance abuse, depression, disruptive behavior (C)
* Cultural and religious determinants of dermatologic healthcare (C)
* Self-prescribing, prescribing and caring for family, friends, and colleagues (C)
* Communications techniques (active and reflective listening, re-interpretation, summarizing; delivering bad news; dealing with non-adherent patients) (E)

C. EDUCATIONAL ETHICS
* Academic honesty: Plagiarism in the digital age, preparing for Board and in-service examinations (C)
* Responsibilities of the trainee to the patient; disclosure, supervision, first-time procedures (C)
* Faculty-resident-student and mentor-mentee relationships; healthy and unhealthy dynamics (E)
* Ethics of residency and fellowship matches (E)

D. ETHICS OF THE BUSINESS OF DERMATOLOGY
* Conflicts of interest and fiduciary interests (C)
* Ethics of self-promotion, marketing, advertising (C)
* Dermatologist-industry relationships (C)
* Ethical issues in cosmetic dermatology, differential waiting times, physician dispensing (E)
* Ethical issues in dermatopathology: client billing, contractual joint ventures, Stark laws and ant-kickback statutes (E)
* Ethical billing and coding and ethical issues in insurance and managed care (E)
* Direct-to-consumer pharmaceutical marketing (E)

E. RESEARCH AND PUBLICATION ETHICS
* Basic concepts of human subjects research, role of IRB, ethics of clinical trials (C)*
* Publication ethics: duplicate publication, “salami-slicing”, self-plagiarism, ghostwriting, authorship issues (C)

F. CLINICAL ETHICS
* Privacy and confidentiality: including basic definitions, HIPAA regulations, digital privacy, electronic mail, social media, patient photography and image storage, telemarketing, consequences of data breaches (C)**
* Informed consent: including substituted judgment, decisional capacity, refusal of care
* Ethical issues in caring for minors (C)
* Medical errors and disclosure, patient safety (C)
* Unreasonable requests for care (E)
* Lying for and to patients (E)
* Ethics of genetic testing, prenatal screening, preimplantation genetic diagnosis (E)
* Ethical issues in teledermatology and global dermatology (E)
* Ethical issues in hospital consultations (E)
* Ethical issues in complementary medicine (E)
* Ethics of physician extenders (E)
* Ethics of cosmetic surgery and enhancement (E)
* Drug sampling (E)

C - core subject    
E - elective subject        
** - most or all may already be taught by institution


Resources for a 3-year Ethics and Professionalism curriculum

based on
University of Connecticut’s curriculum

1.Introduction and Basics: how to recognize and analyze an ethical dilemma

Stoff BK, Scully K, Housholder AL, et al.The American Academy of Dermatology Ethics Pledge: I will put my patients’ welfare above all other interests, provide care that  adheres to professional standards of practice, provide care for those in need, and foster collegiality through interaction with the medical community. J Am Acad Dermatol 2016;75:445-8.

Dermatoethics (pages ix-xiv); Ch 21

Kantor J, Lushniak BD. Excellence in medicine and the case for aspirational ethics. JAMA Dermatol. Published on line June 29, 2016. doi:10.1001/jamadermatol.2016.2135

Bercovitch, et al. Dermatoethics: A curriculum in bioethics and professionalism for dermatology residents at Brown Medical School. JAAD 2007;56(4):679-82

Grant-Kels JM, Bercovitch L. Why a new section dedicated to ethics in the JAAD? J Amer Acad Dermatol 2011;64:432-433.

Garg A, Grant-Kels JM. Ethical considerations in dermatology residency. Clinics in Dermatology 2012;30:202-209

Bervovitch L, Long TP. Ethics education for dermatology residents.  Clinics in Dermatology 2009;27:405-410

Aldrich, et al. Incorporating teaching dermatoethics in a busy outpatient clinic. JAAD 2011;65(2):423-4

Meffert JJ.Ethics? Morals? Values? Clinics in Dermatology 2009;27(4):327-330.

Greenberg RD.The American Academy of Dermatology Ethics Committee: how it works and what you need to know.Clinics in Dermatology 2009;27(4):331-335.

Bercovitch L, Long TP. Ethics education for dermatology residents. Clinics in Dermatology 2009;27(4):405-410.

RESIDENCY EDUCATION

2. See one - do one - teach one: Responsibilities of the trainee to the patient

Dermatoethics Ch 20 

Garg A, Grant-Kels JM. Ethical considerations in dermatology residency. Clinics in Dermatology 2012;30:202-209.

LaRosa C, Grant-Kels JM. See one, do one, teach one: the ethical dilemma of residents performing their first procedure on patients. J Am Acad Dermatol 2016;75(4):845-848.

3. Mentorship-ethical issues & problematic relationships

Dermatoethics CH 18

Maloney ME. Ethical mentorship: the dilemma of success or failure. Clinics in Dermatology 2012:30:210-215

Chopra V, Edelson D, Saint S. Mentorship malpractice. JAMA 2016;315(14):1453-4.

Grant-Kels JM. Mentorship: Opinion of a silver-haired dermatologist. JAAD 2015;73:1066.

4. Ethical issues re: academic honesty, integrity & airplane notes

Grant-Kels JM, Kels BD.  The inner golfer in dermatology:  "You might as well praise me for not robbing banks." Airplane notes and the Board certifying examination.  J Amer Acad Dermatol 2012;67:276-8.

Smith RJ, Lipoff JB. “Pretend you didn’t hear that”- managing ethical dilemmas from the bottom of a medical hierarchy. JAAD 2016;74:766-8.

Lipoff, et al. Reply 2013;68(5):867-9

Bercovitch. Counterpoint: Should dermatology residents accept educational support sponsored or funded by pharmaceutical companies? JAAD 2013;68(5):866-7

Lipoff, et al. Should dermatology residents accept educational support sponsored or funded by pharmaceutical companies?JAAD 2013;68(5):854-7

Chiaravalloti A, Kels BD, Grant-Kels JM. Ethical issues of honesty in advertising: affiliation or exploitation?  J Amer Acad Dermatol – in press

PROFESSIONALISM

5. Professional boundaries: Recognizing & preventing burnout; Ethics of self promotion

Dermatoethics  Chapter 11 (pages 61-66)   & Chapter 25 (pages 147-151)

6. Physician impairment & disruptive physicians; how to respond to unethical behavior of colleagues.

Dermatoethics Chapter 17

Grant-Kels JM, Kels BD. The impaired physician reporting dilemma: Legal, moral and ethical considerations for the practicing dermatologist. J Amer Acad Dermatol 2011;65:833-835.

Kantor J, Rapini RP. Ethical approaches to possible unethical behavior in a physician colleague: A systematic approach. JAAD 2016;74:1026-8.

7. Self prescribing & prescribing for family members/ curbside consults

Dermatoethics Chs 11 and 12

Grant-Kels, et al. The unsolicited ominous diagnosis: Legal, moral, and ethical considerations. JAAD 2012;66(6):985-7

Grant-Kels, et al. The curbside consultation: Legal, moral, and ethical considerations. JAAD 2012;66(5):827-9.

Bercovitch. Should one offer an unsolicited dermatologic opinion? Ethics for the locker-room dermatologist. JAAD 2011;65(1):134-6

Kelsey A, Grant-Kels JM, Payette M. A high tech ethical twist on the curbside consult . J Am Acad Dermatol. 2015;72:349-51.

8. Social media ethics

Dermatoethics Chapter 14

Garg A, Grant-Kels JM. Ethical considerations in dermatology residency. Clinics in Dermatology 2012;30:202-209.

Payette M, Albreski D, Grant-Kels JM. You’d know if you friended me on facebook: Legal, moral and ethical consideration of online social media.  JAAD 2013;69(2):305-7

Luo J, Logan C, Long TP, Bercovitch L. Cyberdermatoethics I: ethical, legal, technologic, and clinical aspects of patient-physician e-mail. Clinics  in Dermatology 2009;27:359-366.

Grenier N, Bercovitch L, Long TP. Cyberdermatoethics II: a case-based approach to teledermatology ethics. Clinics in Dermatology 2009;27:367-371.

9, Ethical issues of multiculturalism & ethnic & religious diversity

Dermatoethics Chapter 15

Shahriari N, Lakdawala N, Grant-Kels JM. Multiculturalism and diversity: How to ethically care for a prejudiced patient.  J Amer Acad Dermatol  2016;75:234-6.

BUSINESS

10. Office dispensing & pricing; Ethics of marketing & promotion; Ethical billing & coding; Conflicts of interest & fiduciary interests

Dermatoethics Ch 23, 24 and 31

Resnik BI. Ethical coding. Clinics in Dermatology 2009;27(4):372-374.

Whitaker-Worth D, Shahriari M, Slade K, Grant-Kels JM.The ethical controversies of office-based dispensing in academic health centers. Clinics in Dermatology 2012;30:528-532.

Castanedo-Tardan MP, Baumann L . Ethics of selling skin care. Clinics in Dermatology 2009;27(4):355-358.

Chiaravalloti A, Kels BD, Grant-Kels JM. Ethical issues of honesty in advertising: affiliation or exploitation?  J Amer Acad Dermatol 2016;75(3):645–647.

11. Cosmetic dermatology & Access to  medical dermatology services; Spa dermatology ethical issues

Dermatoethics Ch 22 & 27

Stoff, et al. The case for equal access to urgent dermatology appointments for Medicaid beneficiaries: When professional duty conflicts with economic reality. JAAD 2015;72(1):181-3

Kels BD, Grant-Kels JM. Conundrum: Who should care for the dermatologic needs of the Medicaid patient? Facts and controversies. Clinics in Dermatology 2013; 31: 769-771.

Stoff B, Bercovitch L, Grant-Kels JM. The case for equal access to urgent dermatology appointments for Medicaid beneficiaries: When professional duty conflicts with economic reality. J Am Acad Dermatol. 2015;72:181-3.

Baumann L. Ethics in cosmetic dermatology. Clinics in Dermatology 2012;30:522-527.

12. Ethical issues in managed care & accountable care organizations; Ethical issues of the Affordable Care Act

Dermatoethics Ch 28

Pariser D. Ethical considerations in health care reform: Pros and cons of the affordable care act. Clinics in Dermatology 2012;30:151-5.

Fenichel S. The ethics of national health insurance: a personal essay.Clinics in Dermatology 2009;27(4):401-404.

13. Ethical issues in dermatopathology

Dermatoethics Ch 29 and ,30

Wiland H, Grant-Kels JM. Ethical issues in dermatopathology. Clinics in Dermatology 2012;30:476-481.

Maley, et al. Should dermatopathologists participate in diagnostic error disclosure to patients? An ethical analysis. JAAD 2015;72(5):901-4

Bercovitch, et al. Electronic health record donations by laboratories: Is legal necessarily ethical? JAAD 2012;66(3):474-8

Grant-Kels, et al. The empty specimen bottle: Legal, moral, and ethical considerations for the dermatologist and dermatopathologist. JAAD 2011;65(3):621-3

Mannava KA, Bercovitch L, Grant-Kels JM. Kickbacks, stark violations, client billing, and joint ventures: Facts and controversies. Clinics in Dermatology 2013; 31: 764-768.

Grant-Kels JM. "Dermatologists' Blind Side: The ethical implications of in house dermatopathology laboratories. J Amer Acad Dermatol 2013;69:1046-1048

Fabbro SK, Stoff BK. The dermatopathologist’s role in genetic testing for hereditary cancer syndromes: Utility versus patient liberty. J Am Acad Dermatol 2016;74:1282-5.

RESEARCH

14. Publication ethics (other topics covered by UCONN required on  line courses)

Dermatoethics Ch 32, 35,36,37, and 38

Slade KL Carreau NA,, Heald P. Ethics of clinical trials in dermatology. Clinics in Dermatology 2012;30:226-230

LaChance A, Murphy M.Ethical Conundrums in research. Clinics in  Dermatology 2012;30:220-225

Olubukola B,Grant-Kels JM, Parrish L. Ethical dilemmas in Journal publication.Clinics in Dermatology 2012;30:231-236.

Straight TM. Clinical research regulation: challenges to the institutional review board system. Clinics in Dermatology 2009;27(4):375-383.

Weyers W. Medical experiments on humans and the development of guidelines governing them: the central role of dermatology. Clinics in Dermatology 2009;27(4):384-394

Shahriari N, Grant-Kels JM, Payette M. Predatory journals: How to recognize and avoid the threat of involvement with these unethical “publishers”. J Amer Acad Dermatol 2016; 75(3):658–659.

Chiaravalloti A, Kels BD, Grant-Kels JM. Ethical issues of honesty in advertising: affiliation or exploitation?  J Amer Acad Dermatol 2016;75(3):645–647.

CLINICAL ISSUES

15. Medical errors; when & how to disclose

Dermatoethics Ch 7      

Maley A, Swerlick R, Parker D, Stoff B. Should dermatopathologists participate in diagnostic error disclosure to patients? An ethical analysis.J Am Acad Dermatol 2015;72(5):901-4.

Wang AS, Eisen DB. Surgical complications: disclosing adverse events and medical errors. J Am Acad Dermatol. 2013;68:144-146.

Dintzis SM, Stetsenko GY, Sitlani CM, et al. Communicating pathology and laboratory errors: Anatomic pathologists’ and laboratory medicacal directors’ attitudes and experiences.  Am J Clin Pathol 2011; 135: 760-5.

Gallagher TH, Waterman AD, Ebers AG, et al. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001-1007.

Dintzis SM, Gallagher TH.Disclosing harmful pathology errors to patients. Am J Clin Pathol 2009; 131: 463-5.

Kachalia A, Kaufman SR, Boothman R, et al. Liability claims and costs before and after implementation of a medical  error disclosure program. Ann Intern Med. 2010;153:213-221.

16. Lying for patients: Is it ever ethical? Unreasonable requests for care

Dermatoethics Ch 2 and 6

 Weston G, Grant-Kels JM. Rothe MJ. The Good, The Bad, and The Ugly of Medication Coverage: Is altering a diagnosis to ensure medication coverage ethical?    Int J Womens Dermatol – in press

Santoro FA, Rothe MJ, Strober BE. Ethical considerations when prescribing biologics in dermatology. Clinics in Dermatology 2012;30:492-495.      

17. Pediatric dermatology ethics; Ethics of genetic testing in dermatology

Dermatoethics CH 4, 5 and 33

Wolz. The modern minor: Consent and decision-making in pediatric dermatology. JAAD 2013;69(6):1043-5

Kelly J, Makkar HP. Ethics in Pediatric Dermatology. Clinics in Dermatology 2012;30:471-5.

18. Teledermatology ethics; Global dermatology ethical issues              

Dermatoethics Ch 8 &16

Stoff, et al. Expanding the reality of short-term international volunteerism in dermatology. JAAD 2015;72:369-370

Stoff, et al. Short-term international volunteerism in dermatology: Ethical considerations. JAAD 2014;71;822-5

Boyd. Reality in short-term international dermatology missions. JAAD 2015;72(:369

Nordlund J. Volunteering for humanitarian projects. Clinics in Dermatology 2009;27(4):395-400.

19. Ethical issues in hospital consultations

Dermatoethics CH 9

Shaw DJ, Maciag M, Bercovitch L.” I didn’t sign on to die”: The dermatologist’s ethical obligations during a deadly epidemic. JAAD 2016;74:183-5.

Hansra NK, Shinkai K, Fox LP. Ethical issues in inpatient consultative dermatology. Clin Dermatol 2012; 496-500

Helms, et al. Hospital consultations: Time to address an unmet need? JAAD 2009;60(2):308-11 

20. Ethical issues relating to use of physician extenders

Dermatoethics CH 10 

Slade K, Lazenby, M, Grant-Kels JM. Ethics of utilizing nurse practitioners and physician assistants in the dermatology setting. Clinics in Dermatology 2012;30:516-521.

21. Ethics in Clinical Photography

Lakdawala N, Fontanella D, Grant-Kels, JM. Ethical considerations in dermatologic photography. Clinics in Dermatology 2012;30:486-491.

Lakdawala N, Bercovitch L , Grant-Kels JM. A picture’s worth a thousand words: Dermatologic photography legal, moral and ethical considerations. J Amer Acad Dermatol 2013;69:473-475.

 22. Ethical issues in dermatologic surgery, cosmetic surgery & enhancement

Baumann L. Ethical issues in cosmetic dermatology. Clincs in Dermatology 2012;30:522-527

Dhossche, et al.Regarding "the use of donated products to train residents to perform injectable cosmetic procedures". JAAD 2015; 72:197-8

Holmes WD, Whalen JD. Ethics in Dermatologic Surgery. Clinics in Dermatology 2012;30:482-5.

23. Drug sampling ethical issues; The dermatologist & pharma, Conflicts of Interest

Vashi NA, Latkowsi J-AM . The ethics of the medical-pharmaceutical relationship. Clinics in Dermatol 2012;30:188-91.

Reid EE, Alikhan,http://www.sciencedirect.com/science/article/pii/S0738081X11001477 - af0010A, Brodell RT. Drug sampling in dermatology. Clinics in Dermatology 2012;30:192-201.

Miner A, Menter A. The ethics of consulting with pharmaceutical companies. Clin Dermatol 2009;27(4):339-45

Meffert JJ. No more pens: what the 2009 Pharmaceutical Research and Manufacturer's Association code changes really mean. Clinics in Dermatology 2009;27:346-9. 

Draelos ZD.Disclosure: a modest proposal. Clinics in Dermatology 2009;27:336-338.

24. Refusal of care; Ethical issues in geriatric dermatology

Stoff BK, Seidler A, Kinlaw K.A patient with dementia: Decision-making capacity and surrogate decision makers JAAD 2012;67:745-7. 

Fontanella D, Grant-Kels, JM, Patel T, Norman R.  Ethical issues in geriatric dermatology. Clinics in Dermatology 2012;30:511-515.

Danesh MJ, Change ALS. The role of the dermatologist in detecting elder abuse and neglect.    JAAD;73:285-93.

Linos E, Berger T, Chren M-M. Point: Care of potentia

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