Clinician develops QI projects to support physicians and improve patient safety.
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Study gathers data to compare skin microbiome’s relation to disease states.
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ALUMNI GALA
Event celebrates how far Dermatology has come.
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VULVAR CLINIC
Retiring physicians leave vulnerable patients in capable hands.
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In an effort designed to improve dermatology medical training, the Educating for Dark Skin Care project aims to advance equity in health outcomes for people of color. The project, funded with a Design Initiative at Dartmouth (DIAD) grant through Thayer School of Engineering, is a collaboration between the Department of Dermatology and the Department of Medical Education to create more diverse
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Dartmouth Hitchcock Medical Center DEPARTMENT OF DERMATOLOGY
Alicia Dagrosa TU’16, MED’17, RES’21, FAAD (from left), Shahin Shahsavari ’25, Chiamaka Okorie ’23, and Lynn Foster-Johnson, PhD, are partnering with the DEV Studio and Thayer School of Engineering to improve dermatology resources, curriculum, and training.As we begin to leave behind the constraints of the pandemic, the challenges we face in dermatology—and healthcare in general— persist. Our workforce in the department has shrunk, and our ability to hire and train new staff remains difficult, despite the surging demand for our services in an aging population. However, regardless of these obstacles, our department continues to thrive.
Among our successes are our new “SuperDerm” clinics, which strategically funnel patients with low-complexity conditions into a clinic environment with increased resources, such as space and staffing, and more quickly move them through the clinic, with the same high-quality care. Not only have our patients been highly satisfied with these self-selected visit types, but our staff, residents, and faculty have also been pleased. Everyone wins!
We have also addressed the issue of burnout—the loss of joy in our work—by instituting flex days, which physicians can use as they see fit. This may be selfcare, catching up on notes, or spending time with family. We continue to tweak and modify this concept with the notion of taking care of ourselves while we take care of others. While it may be small, I think it is a move in the right direction. And to continue this theme: Julianne Mann MED’07, recently completed her fellowship at the Institute for Healthcare Improvement (IHI)—the first such fellowship given to a provider at Dartmouth Health (DH)—and she is leading DH’s quality improvement projects focused on patient and physician well-being.
Our efforts to engage Geisel School of Medicine students in the department’s research program is paying off. Alicia Dagrosa TU’16, MED’17, RES’21, FAAD, the director of medical student education, has created a system and culture of inviting Geisel students under our Dermatology umbrella early in their medical careers, giving them the opportunity to work on multiple research projects in basic science, clinical trials,
and medical publications. These students have felt so empowered that they have initiated projects based on their own interests, including expanding dermatology education around skin of color, mentioned in this newsletter. This is how we envisioned our department to be involved with Geisel, and it is rewarding for all of us to see this partnership come to fruition.
Among our many pursuits shared in this newsletter are the cutaneous microbiome research project and the transition at the vulvar clinic. We will share updates about the Down syndrome clinic and the new hidradenitis suppurativa clinic in the future. We are also expanding our telehealth capacity to include several small critical access hospitals in our rural region. And we will soon launch four National Institutes of Health funding submissions, the most we have ever attempted.
Our department has found ways to thrive in some tough circumstances thanks to our family atmosphere and spirit of teamwork. We also have seen some unbelievable leadership from our faculty, administration, and nursing group, and I anticipate 2023 will be another banner year in the Department of Dermatology.
Inaugural Chair, Department of Dermatology, Dartmouth Health’s Dartmouth Hitchcock Medical Center Professor of Dermatology, Geisel School of Medicine at Dartmouth
The Department of Dermatology invited its alumni, faculty, residents, and friends to participate in the 41st Prouty event on July 9, 2022. The Prouty is an annual fundraising effort at Dartmouth Cancer Center that includes many sporting events, such as bicycling, walking, rowing, and golfing.
The 2023 Prouty will be held July 15, and the Department of Dermatology once again invites everyone from near and far—and even virtually—to join the event and support the fight to end cancer. Visit the Prouty website at www.theprouty.org
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dermatology teaching materials for medical students. Geisel School of Medicine professors Alicia Dagrosa TU’16, MED’17, RES’21, FAAD, and Lynn Foster-Johnson, PhD, along with medical students Chiamaka Okorie ’23 and Shahin Shahsavari ’25, are partnering with the Dartmouth Data Experiences and Visualizations Studio (DEV Studio) and the DIAD team to develop a prototype for a design-thinking-based web resource called Dart Derm. The team expects this resource will provide better training for treating dermatologic diseases across a range of skin tones. Dart Derm will use innovative imaging of disease characteristics and corresponding pathology, authentic patient scenarios, and culturally relevant resources reflecting the experiences and practices of Black, Indigenous, and people of color (BIPOC) communities.
“Skin of color is underrepresented in our medical education nationwide,” Dagrosa says. “Some studies show that the ability of medical students to correctly identify and manage skin diseases in skin of color is lower than in lighter skin tones. Insufficient preparation and knowledge of different skin tones can lead to misdiagnoses. We want students coming from Dartmouth to have exposure to seeing and treating skin disease in all skin tones.”
In course feedback over the years, students have indicated they want more education around different skin
tones to feel more fully prepared to treat all people. Dagrosa notes that while it’s critical for dermatologists to be proficient in diagnosing skin disease in all skin tones, it’s also important for physicians in any discipline to have this experience. A large percentage of skin conditions are diagnosed and treated by nondermatologists, so the team plans to incorporate Dart Derm in the Dermatology course and make the resource available for use in other courses in the second-year curriculum.
of dermatologists who may treat patients anywhere in the world.
Medical students Okorie and Shahsavari say they are excited about the project because it’s a resource they would find valuable.
“We are working to create something I would have loved to see as a student,” Okorie says. “In dermatology, one of greatest things we have is the gift of touch. You can see a lesion, but you also want to know how it feels. Since we’re collaborating with experts in designthinking, we hope to have 3D images instead of just the flat images we currently have.”
The Dart Derm resource—a collection of interactive, potentially 3D learning modules—will augment a teaching database of Kodachromes compiled in a past project led by Dartmouth dermatologist Denise Aaron RES’06. These Kodachromes feature images of different disease presentations in a variety of skin tones. Dagrosa and her team are collaborating with the DEV Studio to develop the technology for the modules. In the initial phase, the team will create the prototype for the modules with one skin disease. Foster-Johnson will lead the curriculum design and assessment activities.
Dagrosa stresses the necessity of visual learning for dermatology, looking at the disease presentation directly on patients’ skin or in images. Because the demographic of the rural New England region is largely white, images of different skin tones are needed for the education
Before beginning medical school, Shahsavari created online teaching materials as a workshop instructor in bioinformatics, and he made this content publicly available. He emphasizes the value of highquality, open-access educational resources, and he hopes that one day the Dart Derm resource might also be publicly available. “Creating a resource for dermatology training would significantly assist with access to highquality education and improve the care we provide to patients,” he says.
Dagrosa says she is looking forward to exploring the possibilities of what this web-based resource could become in the future.
“We have so many innovative people with that area of expertise right here in the Dartmouth community,” Dagrosa says. “I’m excited to work with the DEV Studio to see where our combined efforts can take us. I hope this collaboration will improve education, equity, and long-term health outcomes.”
Insufficient preparation and knowledge of different skin tones can lead to misdiagnoses. We want students coming from Dartmouth to have exposure to seeing and treating skin disease in all skin tones.”
Alicia Dagrosa TU’16, MED’17, RES’21, FAAD, assistant professor of dermatology and medical educationJulianne Mann MED’07, section chief of pediatric dermatology and director of quality improvement
As the first Dartmouth Health (DH) physician to receive a fellowship at the Institute for Healthcare Improvement (IHI), Julianne Mann MED’07, section chief of pediatric dermatology and director of quality improvement (QI), is passionate about improving processes to deliver better care to patients and to support the well-being of healthcare workers. Her QI methodology draws on clinical science, systems theory, psychology, and statistics to develop bold, inventive new workflows.
“Historically, QI initiatives and metrics have focused almost exclusively on the inpatient hospital realm,” says Mann, who recently completed the IHI fellowship. “The Department of Dermatology is leading the way on ambulatory QI at DH. We’re creating a vibrant culture of continuous improvement and piloting some exciting improvement initiatives.”
Mann is pioneering a new approach to addressing physician burnout, which is at record levels in the United States. “One of the biggest contributors to physician burnout is the hours we spend in the evenings signing chart notes in the electronic health record (EHR),” she says. “It’s emotionally and physically exhausting to see a large number of patients during the day and then have to stay up late at night charting on the computer. Physicians need to recharge and connect with their families in the
evenings to stay well and give patients the best possible care.”
For this pilot study, Mann is evaluating the effect of a professional coaching program on physicians’ ability to get their chart notes signed during the workday. Through workflow changes, reducing interruptions
they are a tool for care coordination and patient safety. Mann says she now regularly signs 80% to 90% of her notes during her workday and has almost entirely eliminated her evening EHR charting time.
We’ve gotten so much positive feedback from faculty. They feel like they’re getting their lives back.”
“We’ve gotten so much positive feedback from faculty. They feel like they’re getting their lives back,” says Mann, who notes this approach doesn’t require hiring additional staff or reducing the number of patients a physician sees.
Julianne Mann MED’07 section chief of pediatric dermatology and director of QIand distractions, and adopting a “team sport” mindset, nurses and physicians are working together to sign notes efficiently after each patient is seen. Notes completed in real-time are more accurate, and because they are immediately viewable to other physicians at DH,
go.d-h.org/derm
Mann’s QI work also includes an initiative to reduce errors that occur during skin biopsies. She and Caitlin Yazel, APRN, dermatology nurse manager and vice chair of clinical operations, have developed a biopsy time-out that is now universally used in the Heater Road dermatology clinics. While time-outs have been used for years in operating rooms, there is no
Clinician researcher develops QI projects to improve provider well-being and patient safety
broadly used analogous process for ambulatory surgical procedures. “Even the smartest and most conscientious healthcare workers can make mistakes—we are human beings,” Mann says. “It’s critical to have a system of safety and crosschecks for surgical procedures in ambulatory settings.”
Before the biopsy begins, the dermatologist, nurse, and patient all pause to verify critical information. Once the biopsy is completed, everyone in the room visually confirms that the specimen is in the bottle and correctly labeled. Mann and her team are tracking the number of errors before and after instituting the time-out, and early data show an encouraging trend. Patients are giving positive feedback, too, expressing appreciation for the focus on accuracy and safety.
Looking to the future of QI at DH, Mann highlights the importance of engaging clinicians. “Physicians and nurses know which aspects of our care delivery systems need to be changed for the better,” she says. “When we empower them to lead, we see real transformation.”
Together with Carol Barsky, MD, chief quality officer at DH, and Lara Goitein, MD, of Dartmouth Health’s Value Institute Learning Center, Mann sees a bright future at DH where physicians and nurses inspire and guide meaningful systems-level change. She stresses that more funding is needed to support QI-focused physicians.
“We need at least one physician in every department with the skills, training, and protected time to do this work,” Mann says. “I think Dartmouth Dermatology can lead the way on this.”
The microbiome of the gut has been well studied, but data about the many microorganisms living on the skin and how they relate to skin disease is lacking. Dorothea Barton MED’07, RES’11, section chief of Complex Medical Dermatology, is seeking to change that.
Collaborating with her colleague Matthew Hayden, MD, PhD, director of basic research in the Department of Dermatology, as well as with a research fellow and several medical students, Barton is currently working to hone the methodology of collecting and growing samples of the whole living microbiome on the skin. The goal is to create a database of the skin flora to be able to compare the cutaneous microbiome in different disease states.
“In some disease states, there’s too much bacteria. If there’s too much of a pathogenic bacterium like staph aureus, for example, you get a clinical infection,” says Barton, whose research is supported by The Richard D. Baughman, MD, Scholar Endowment, established by Barbara and Dick Couch D’64, TH’65. “But not all bacteria is bad. The skin microbiome interacts with the immune system, controls inflammation, and plays a role in fighting infection. We’re looking at dysregulation of bacteria and what role it may play in skin disease.”
And if it does play a role, Barton says, researchers can eventually study whether correcting the microbial dysregulation can help treat the disease. She notes the popular attention given to altering the body’s microbiome in an unscientific way, such as by taking overthe-counter probiotics or using drug store lotions. But the question remains—are these products helpful or harmful in certain skin diseases? For example, in some studies, probiotics have been shown to improve outcomes, such as in atopic dermatitis. But other studies suggest probiotics may contribute to diminished clinical benefit of certain types of therapy in melanoma patients.
“Right now, we don’t know very clearly what it is that we’re altering and how that plays into disease,” Barton says. “First we must categorize the differences in the microbiome among these skin diseases. Then we can study whether altering the skin microbiome can improve disease states. There is still a lot to be learned.”
As a celebration of the elevation of Dermatology to a full department at Dartmouth Health, more than 150 alumni gathered for the July 2022 reunion and gala. “The gala was a joyous and memorable event that brought so many graduates back to celebrate with us,” said Richard (Dick) Baughman, MD, emeritus professor of Dermatology. “It was a recognition of how much work had gone into reaching that department status and a recognition of the importance of our specialty of dermatology in both medical and surgical components.”
The event showcased posters full of photographs of past events with dermatology faculty, nurses, and alumni. Baughman says the reunion and gala highlighted the increases in faculty, residents, and research activities to alumni who came from near and far to attend, several of whom graduated as long ago as the 1960s.
“Every dermatologist who has graduated from the program knows how well they’ve been prepared to take care of the skin and meet the needs of their patients,” said Mike Stierstorfer, MD, who completed his dermatology residency at Dartmouth Hitchcock Medical Center in 1989. “I was really impressed to hear of the accomplishments of all the former residents. It was also great to catch up with old friends—fellow dermatologists
as well as nursing and administrative staff—and to make new ones.”
William (Bill) MacEachern, MD, completed his dermatology residency in 1963. He passed away before the reunion, so his daughter Martha MacEachern attended the event in his place. “Dartmouth Dermatology was a huge part of his life,” said MacEachern, who lives in Ontario, not too far from her parents’ home in Waterloo, Ontario. “He visited New Hampshire regularly to spend time with Dr. Baughman and others from the department. He shared their pride about dermatology’s growth over the years.”
MacEachern said she felt honored to attend the event. “So many people came up to me and said they had known my dad and been influenced by him,” she said. “It was a special opportunity to celebrate him. The gala was a true reflection of the program’s history and where the department is now. My father would be so proud.”
Brian Simmons RES’20, the director of clinical trials for the Department of Dermatology, recently received a Dermatology Foundation Research Award—and is the first Dartmouth Health provider to be awarded this grant.
Simmons’ research involves unlocking the potential for using CRISPR technology as a point-of-care test to diagnose fungal skin infections. Such
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Alumni, current and former faculty and staff, and their families, summited Mt. Cardigan on a beautiful fall day during reunion weekend in support of the 41st Prouty. See page 2 for information on how to join the dermatology team at the Prouty this July.
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Gala attendees enjoyed a night of reconnecting with mentors, colleagues, and friends, reflecting on the history of Dartmouth dermatology, recognizing the contributions of leaders and the accomplishments of residency program alumni, and celebrating the new status as a department.
a test, which uses an enzyme to target a particular DNA sequence, has been shown to diagnose fungal infections within minutes using in vitro models. This kind of test could replace time-consuming lab tests to analyze fungal skin scrapings. Not only is the CRISPR method faster, it’s also less costly and can be used in resourcepoor areas using simple supplies.
In addition to the grant providing the opportunity to advance his own research, Simmons notes that the $25,000 award acts as a springboard for the department to earn more funding from the foundation as well as from the National Institutes of Health and other organizations.
“This award opens the door for my personal career, my colleagues, and the department to potentially earn grants for other research projects,” Simmons said. “It’s also an opportunity for a Geisel medical student to potentially earn funding from the Dermatology Foundation for an internship to assist in research.”
Simmons will use the foundation grant to conduct the next step, of his research using human skin samples, and he hopes his findings may one day lead to new diagnostic tests for other skin infections, such as staph, strep or herpes. He expects to have data to present to the Dermatology Foundation by the summer.
at the clinic to treat these complex cases, such as vulvar lichen sclerosus. Crohn’s disease is also linked to skin conditions that can present in the genital area.
Dermatologists
Lynne
Lynne Margesson, MD, who recently retired from the Department of Dermatology, admits she knew nothing about the area of gynecologic dermatology when she first began working with people who had vulvar skin diseases.
“The vulva is an area of taboo, and there are enormous problems with lack of education,” says Margesson, who has been involved with vulvar skin diseases for nearly 40 years. “Residents would tell me they didn’t know what ‘normal’ looks like, so they didn’t know what they were seeing. We need to get medical providers comfortable with looking at vulvas.”
Because she had no training for treating vulvar skin diseases, Margesson realized the benefit of partnering with a gynecologist to manage these cases, and she started a clinic at Queen’s University in Kingston, Ontario—the first clinic in Canada to combine these two specialties.
She says her training came with one patient at a time—because there was no formal medical training in the field of gynecologic dermatology. “I went to every meeting, every lecture I could find where someone could teach me something about women.”
For the past 23 years, Margesson has provided this expertise to patients at the Dartmouth Health (DH) vulvar dermatology clinic. She teamed with Debra Birenbaum, MD, an obstetrics and gynecology provider who also recently retired from DH. The two physicians have passed the torch to dermatologist Denise Aaron RES’06, and gynecologist Angela “Frannie” Koenig, MD, who offer a multidisciplinary approach
“Some people come to the clinic with vaginal discharge, and a dermatologist can see in an instant that it’s cutaneous Crohn’s disease,” Margesson says. “With education, physicians can recognize these medical conditions more quickly because it’s pattern recognition. That’s why dermatologists are good at this—they are taught pattern recognition.”
The physicians taking over the vulvar dermatology clinic are equally dedicated to their patients.
“I want to alleviate suffering,” says Aaron, who has worked with the the vulvar clinic since 2021. “This is a population who struggle to find help in our current medical system—not fitting in dermatology and not fitting in gynecology. Having a gynecologist as part of the patient’s exam expands what I would have known as a dermatologist.”
Koenig appreciates having a dermatologist in the room during clinic appointments to better help their patients. “We both bring our own knowledge,”Koenig says. “And we’re gaining education in the other doctor’s expertise.”