Community Practice Research Articles

Transitioning to rural practice together: a rural fellowship model (in 6 Ps).

Maintaining a robust healthcare workforce in underserved rural communities continues to be a challenge. To better meet healthcare needs in rural areas, training programs must develop innovative ways to foster transition to, and integration into, these communities. Mountain Area Health Education Center designed and implemented a 12-month post-residency Rural Fellowship program to enhance placement, transition, and retention in rural North Carolina. Utilizing a '6 Ps' framework, the program targeted physicians and pharmacists completing residency with the purpose of recruiting and supporting their transition into the first year of rural practice. To better understand Rural Fellows' experiences and the immediate impact of their Fellowship year, we conducted a semi-structured interview using a narrative technique and evaluated retention rates over time. Interviews with the eight participants, which included Fellowship alumni and current Fellows, demonstrated the impact and influence of the key curricular '6 Ps' framework. An early retention rate of 100% and a long-term retention rate of 87%, combined with expressed clarity of curricular knowledge, skills, and attitudes related to the '6 Ps', demonstrate the potential and effectiveness of this Rural Fellowship model. Participants indicated the Rural Fellowship experience supports the transition to rural practice communities and expands their clinical skills. The Rural Fellowship program demonstrates an effective model to support early career healthcare providers as they begin practice in rural communities in western North Carolina through academic opportunities, personal growth, and professional development. Implementation of this model has demonstrated the success of a rural retention model over a 6-year period. This model has the potential to target an array of clinical providers and disciplines. We started with family medicine and have expanded to psychiatry, obstetrics, pharmacy, and nursing. This study demonstrated that this model supports clinical providers during the critical transition period from residency to practice. Targeting the most important stage of one's medical training, the commencement of professional practice, this is a scalable model for other rural-based health professions education sites where rural recruitment and retention remain a problem.

Recruitment and retention of new doctors in remote and Aboriginal medical services through the Remote Vocational Training Scheme's Targeted Recruitment Strategy: a focus group study.

To explore the results of a targeted recruitment strategy designed to attract and retain new doctors in remote and Aboriginal medical services where they can access Remote Vocational Training Scheme (RVTS) training and support to qualify as general practitioners. Two 2-hour purposeful online focus groups on the RVTS' Targeted Recruitment Strategy. Five participants and nine stakeholders with knowledge and experience of the strategy. Data were transcribed and deductively and inductively coded for themes including insights from separate project reference and stakeholder advisory groups. Perspectives of the strategy. The overarching theme was that the strategy is useful for attracting and retaining new general practitioners in areas of high need and is potentially scalable. Since 2018, 20 new doctors were recruited via the Targeted Recruitment Strategy and six of them completed the RVTS program. The strategy could better differentiate target locations because increasing communities are experiencing major general practice workforce shortages. The package of employment and training could also be more clearly defined for participants, nationally marketed and collaboratively implemented. Further, more site accreditation and ongoing risk and quality review is needed, along with intense early supports for participants who are new to both the community and general practice work. The Targeted Recruitment Strategy is still maturing but the early results suggest it is a unique and proactive model for attracting and improving access to general practitioners in places with high needs. It could be strengthened through formal agreements between communities and agencies, ensuring coordinated implementation, clarifying roles and responsibilities, and developing clear pathways for risk and quality management.

7812 Community Practice Setting Experience in Evaluation of Incidental Thyroid Nodules

Abstract Disclosure: N. Abate: None. H. Rhodes: None. M. Horlavadi: None. B. Adams-Huet: None. M. Chandalia: Advisory Board Member; Self; Boehringer Ingelheim. Speaker; Self; Boehringer Ingelheim, Eli Lilly & Company, Novo Nordisk. Background: There is a significant increase in detection of incidental thyroid nodules due to increase in routine screening ultrasounds at church, workplace, and health fairs, increase in routine ultrasound in primary care clinics and incidental finding of thyroid nodule during carotid artery ultrasound. These patients are then referred for thyroid nodule fine needle aspiration biopsy. Aim of this study was to evaluate real world data in frequency of thyroid cancer in patients referred for incidental thyroid nodule to a nonacademic Endocrinology clinic utilizing centralized collection of cytology and molecular analysis. Method: Medical records were reviewed for consecutive FNA of incidental thyroid nodule in an Endocrinology clinic in greater Houston from 2021 to 2023. FNA was performed in patients selected based on ACR TI-RADS classification. Patients with Bethesda score of 3 or more had molecular testing with Thyroseq performed. Patients with intermediate or high probability of cancer on Thyroseq as well as Patients with Bethesda 4 and 5 on cytopathology were referred for surgery. Surgical pathology was obtained in patients who underwent surgery. Data was tabulated and analyzed using SAS. Results: A total of 304 subjects, 267 Female and 37 males, age 57 ± 13, nodule size 2.69 ± 1.4 (mean ± SD), had thyroid nodule FNA between 2021 and 2023. Of these FNA, 23 (7.5%) sample collections were insufficient, 233 (77.3%) were benign (Bethesda 2), 46 (15%) were Atypia of undetermined significance or Suspicious for malignancy. Of those subjects with Bethesda 3 or higher, 36 patients had molecular testing by Thyroseq Method. Fifteen patients had intermediate and high risk finding on Thyroseq. Thirty-four subjects had surgery and 8 patients had malignancy on surgical pathology. One patient was identified as Medullary Thyroid cancer on Thyroseq, confirmed by surgery. Frequency of malignancy in incidentally detected thyroid nodule in the whole group was 2.6%, those with Bethesda 3 and more was 17.4% and those with Thyroseq intermediate or high risk was 27%. Conclusion: Availability of centralized cytopathology and reflex molecular testing to Community practice settings helps reducing unnecessary thyroid surgeries in patients with incidental thyroid nodules. Presentation: 6/1/2024

Navigating tensions between economic and social integration among immigrant family entrepreneurs: a paradox perspective

ABSTRACT This study explores the intricate dynamics of immigrant family entrepreneurship, examining how immigrant family entrepreneurs navigate tensions between economic and social integration for sustainability through three longitudinal case studies of immigrant family businesses. Utilizing paradox theory, we offer a multi-dimensional perspective that captures the complexity of immigrant family businesses in Sweden. Our research enriches existing theoretical frameworks on immigrant family entrepreneurship by considering both economic and social facets in tandem. Our findings underscore the pivotal role of the family in navigating the tensions of immigrant family entrepreneurship, with family members acting both as facilitators and inhibitors. Our insights can guide policymakers and practitioners in fostering more inclusive and sustainable immigrant entrepreneurial communities in practice. This study contributes to the broader discourse on sustainability challenges in immigrant family entrepreneurship, aligning with the goals of social and economic sustainability.

Socio-Economic Impact of Homestay: A case study of Tharu Homestay Patalganga, Birendranagar 3, Surkhet

Homestay tourism has been emerging as a form of sustainable tourism in many rural areas as a community development program in Nepal. The entire activities from the particular location have been integrated as a major component of rural tourism in homestay programs.To examine the socio-economic status of homestay owner. This study having the objective to explore the cultural practices of Tharu community, examine the socio-economic status of homestay owner describe the demographic pattern of the study area. Tharu community from Patalganga has been operating homestay programs where guests are offered only basic facilities i.e. normal bed just as the host sleep in their own bed, local food as host normally eat, and unique traditional hospitality with different cultural and natural beauties of particular area. Local cultural activities, traditional lifestyle of host, local tests can be experienced by guests taking part in a homestay program.Tharu people are rich in culture, have their own language, custom, and culture. This Patalganga community homestay perform the following cultural dance to entertainment the tourists like circle dance, stick dance and sakhiyadance. There are some challenges for doing home stay business in Patalganga village. The qualitative characteristics of social capitals such as road, transportation, energy, communication, security, are not supportive to the homestay. Homestay in Patalganga has created an alternative source of income for the concern family of the homestay operators. However, the families face the internal and external problems in the entire homestay. Homestay is a very effective tourism tool for economic sustainability, and natural sustainability of rural community by preserving the local tradition and culture.

Sustainable livelihoods following an extreme event: Post‐earthquake practices of the Tibetan community in Jiuzhaigou World Heritage site, China

Sustainable livelihoods following an extreme event: Post‐earthquake practices of the Tibetan community in Jiuzhaigou World Heritage site, China

Storytelling and good relations: Indigenous youth capabilities in climate futures

AbstractHow can we support young citizens facing chaotic climate futures? This question is urgent, particularly for Indigenous communities who face disproportionate risks and impacts of climate change. For the past three decades, climate‐related education has focused largely on the acquisition of scientific knowledge in instrumental ways, while encouraging individual behaviour change. This approach centres the problem rather than human capabilities to generate solutions, which is especially misaligned with the increasing practice and significance of Indigenous communities’ regenerating self‐determining capabilities. This article reports on a pilot study that uses intergenerational storytelling methods or pūrākau to support leadership capabilities among Indigenous Māori and Pacific young people aged 10 to 14 years in communities at high risk of flooding in Ōtautahi/Christchurch, Aotearoa/New Zealand. The study showed how storytelling locates and scaffolds Indigenous young people into positions of individual and collective responsibility for grappling with “wicked problems” such as climate and injustice and climate‐related challenges as part of the future they will inherit and shape within a broader intergenerational journey of resilience and reclamation.

Primary Eyecare Glaucoma Service (PEGS): a mixed methods service evaluation.

A pilot study to assess the safety and efficacy of a Primary Eyecare Glaucoma Service (PEGS), with low-risk glaucoma patients being reviewed within primary care optometry. 98 low-risk glaucoma patients were identified as suitable for monitoring in primary care and reviewed by accredited optometrists in community practice supported by a clinical management plan. Safety was assessed by reviewing concordance of management plans created by primary care optometrists and the secondary care team. Patients' and primary care optometrists' feedback were collated via surveys. Carbon emissions were calculated through comparison of patient travel to primary and secondary care. 93.8% of patients reviewed by primary care met criteria for ongoing monitoring in primary care after initial review with 4.9% of patients being recalled to secondary care due to clinical instability. Safety and efficacy were demonstrated with agreement of management plans between primary and secondary care of 97.8%, kappa =0.88 (95% confidence intervals 0.60-1.00), with no patients being identified as false negatives where recall back to secondary care was required. Overall satisfaction with PEGS was 100% according to a patient survey. Respondents of the primary care optometry survey felt very or somewhat confident in delivering care, with comments suggesting they felt supported by secondary care. Carbon emissions are reduced by approximately two thirds when patients are seen in primary care versus attending the hospital. PEGS is a safe and effective service, reducing the burden for secondary care, while carbon emissions are reduced due to shorter travelling distances, demonstrating environmental sustainability.

Inter-reader reliability and diagnostic accuracy of PI-RADS scoring between academic and community care networks: How wide is the gap?

ImportanceThe Prostate Imaging Reporting & Data System (PI-RADS) scoring guidelines were developed to address the substantial variation in interpretation and reporting of prostate cancer (PCa) multiparametric MRI (mpMRI) results, and subsequent updates have sought to further improve inter-reader reliability. Nonetheless, the variability of PI-RADS scoring in real-world settings may represent a continuing challenge to the widespread standardization of prostate mpMRI and limit its overall clinical benefit. ObjectiveTo assess variability in mpMRI interpretation and reporting of PCa, we evaluated the discrepancies in PI-RADS scoring between community practices and a tertiary academic care center. Design, setting, and participantsWe identified 262 mpMRI studies from nonacademic facilities, reinterpreted by radiologists at our institution between January 2016 and July 2022. Results of targeted MRI fusion biopsy were identified for 193 of these patients, totaling 302 lesions. PI-RADS scoring from both community and academic interpreters were recorded in addition to presence of clinically significant PCa (csPCa) on pathological analysis of targeted cores. Main Outcome and measuresThe primary outcome was inter-reader reliability via intraclass correlation (ICC) and the kappa statistic. We also assessed the diagnostic accuracy of PI-RADS scoring for detecting csPCa for both cohorts via receiver operator characteristics (ROC) analysis and compared these findings using paired-sample area difference under curve analysis. ResultsInter-reader agreement and reliability of PI-RADS scoring per lesion was generally poor (absolute agreement ICC = 0.393, 95% CI: 0.288–0.488; consistency ICC = 0.407, 95% CI: 0.308–0.497; kappa = 0.336, 95% CI: 0.267–0.406). Reliability results from studies obtained after the publication of PI-RADSv2.1 were similar to those of the overall analysis. No agreement was observed in the subgroup of lesions scored as PIRADS 3 by community interpreters. No statistically significant difference in diagnostic accuracy was observed between cohorts (ROC area under curve [AUC]: 0.759 vs. 0.785, respectively; P = 0.337). PI-RADS 3 was determined to be the optimal cutoff for detecting clinically significant disease in both cohorts. Conclusions and relevanceOur results suggest that mpMRI diagnostic accuracy for detecting csPCa is not significantly different between academic and community practices. However, significantly poor reliability of mpMRI was observed between cohorts, suggesting the risk of introducing practice variation for community prostate cancer management. Variability, particularly for PI-RADS 3 lesions, can lead to inconsistent biopsy recommendations, which may result in missed csPCa or unnecessary biopsies.

History and practices on the magnanimity and sanctity of diet

From prehistoric hunter-gatherer societies to the sophisticated gastronomy of medieval royal courts, the evolution of Indian food culture underscores the integral role of food in sustaining life and fostering communal bonds. Beginning with the ancestral legacies where food was regarded as a divine gift fostering communal eating and social cohesion, this article explores the progression of food culture through the lens of historical epochs such as the Harappan civilization, Vedic period, Mauryan and Gupta periods, and the influences of Dravidian culture, Muslim rulers, and European colonization. The article highlights the pivotal role of Prana, the life force in digestion, as described in texts such as the Chandogya-Upanishad, and the impact of food on mental purity and vitality. It examines the classification of food in the Bhagavad Gita based on its effects on the Gunas (qualities), emphasizing the preference for Sattvika foods that promote longevity and happiness. The Manusmritiunderscores the cosmic significance of food offerings, linking human actions to natural elements and divine beings. The practice of Annadanam (the giving of food) is extolled as one of the highest forms of charity, reflecting a universal ethos of generosity and hospitality. The comprehensive review underscores the holistic understanding of the sanctity of food within the intricate fabric of Indian culture, intertwining spiritual beliefs, ethical considerations, and communal practices that have shaped culinary traditions and societal norms over millennia.

Community and academic allergists’ perspectives on integrating biologics into food allergy care: A qualitative study

BackgroundBiologics are an important area of research and development, including for treatment of food allergy (FA). However, how allergists perceive the risks and benefits of biologics to treat FA remains largely unknown. ObjectiveTo explore how US-based allergists perceive the use of biologics in FA treatment. MethodsUsing a combination of purposive and snowball sampling, providers were recruited through direct solicitation by email to participate in a telephone or Zoom interview about their perceptions of the risks and benefits of current and future FA treatment options. Interviews were transcribed, deidentified, and coded to conduct a thematic analysis. ResultsWe conducted 60 interviews with providers from 34 states working either in community practice (53.3%) or academic medical centers (46.7%). Our sample was primarily non-Hispanic White (60.0%) and men (56.7%). The plurality was in their 40s (41.7%). Our findings clustered in the following 4 main themes: (1) perceived benefits of biologics, (2) ideal use of biologics, (3) concerns about biologics, and (4) biologics as the perceived future of FA. Community and academic providers had largely similar views, but academic providers more often emphasized the benefits of biologics, and community providers were, on the whole, more supportive of using biologics as an adjunct to oral immunotherapy rather than as monotherapy. ConclusionThis study indicates that providers hold mixed views about the use of biologics to treat FA. However, most were enthusiastic about prescribing biologics for FA while also being highly concerned about the cost to patients and the health care system.

S1540 Outcomes of Endoscopic Liquid Nitrogen Cryotherapy for Palliation of Esophageal Cancer in Community Practice

S1540 Outcomes of Endoscopic Liquid Nitrogen Cryotherapy for Palliation of Esophageal Cancer in Community Practice

EP.07D.05 Molecular Testing Care Gap Analysis of EGFR Mutation for Early-Stage NSCLC Patients in Community Practices

EP.07D.05 Molecular Testing Care Gap Analysis of EGFR Mutation for Early-Stage NSCLC Patients in Community Practices

S1392 Outcomes of Invisible Dysplasia Found on Random Biopsy Referred for Chromoendoscopy in a Community Practice

S1392 Outcomes of Invisible Dysplasia Found on Random Biopsy Referred for Chromoendoscopy in a Community Practice

Increasing access to biomarker-driven treatment for lung cancer in Alabama: The Alabama Access initiative.

159 Background: Lung cancer is the leading cause of cancer death in Alabama, with an estimated 2,550 deaths in 2024. Non-small cell lung cancer (NSCLC) represents 85% of these cases. Despite national guidelines recommending comprehensive biomarker testing (CBT) for metastatic NSCLC, significant disparities persist in the utilization of CBT and targeted therapies among Alabama residents. Methods: In March 2024, we launched the "Alabama Access" initiative – a partnership between the LUNGevity Foundation and the O’Neal Comprehensive Cancer Center at the University of Alabama at Birmingham – to foster academic and community oncology partnerships to increase access to biomarker-driven treatments. We used a population health science and geospatial mapping approach to visualize oncology practices serving counties with Alabama's highest lung cancer burden. Practices in Walker, Dothan, Marengo, Morgan, Jackson, Marshall, and Montgomery counties were identified as the highest priority based on annual mortality rates. Key interventions will include virtual molecular tumor boards and oncology navigation to facilitate the integration of resources and expertise and ensure that patients in nonacademic practices benefit from the latest advances in precision oncology. After roll-out, we will collect feasibility and acceptability data around program integration. Results: Our analysis revealed that 62.0% of the state’s population resides in Primary Care Health Professional Shortage Areas (HPSAs), and 58 out of 67 counties are classified as Medically Underserved Areas. The poverty rate in 89.6% of counties surpasses the national average, contributing to higher lung cancer incidence and mortality rates, with 62.0% of cases diagnosed at advanced stages. The state also shows a higher smoking prevalence, affecting 97.0% of counties compared to national figures. We will present practice-level testing data, including barriers to CBT. Conclusions: This pilot aims to mitigate disparities in CBT through enhanced collaboration between academic and community oncology settings. Integrating molecular navigation into community practices will be pivotal in disseminating program information and collecting data on current testing practices to improve overall lung cancer care quality in Alabama.

Social Media and Crisis Informatics Research in LIS

ABSTRACTCrisis informatics is centrally situated within the realms of LIS research and practice, given the focus on the interconnection between information, people, and technology during disasters such as hurricanes, earthquakes, wildfires, and global health crises. However, there is yet to be a community dedicated to crisis informatics research at ASIS&T, where researchers can exchange theoretical frameworks, the latest methodologies, and collected datasets, potentially fostering long‐term collaborations. Therefore, this panel proposes to bring together scholars within LIS who have been active contributors to crisis informatics research, from multiple perspectives ranging from critical librarianship, machine learning, and human‐computer interaction (HCI), to mixed‐methods approaches. The panelists will first share their most current crisis‐related research project and how they envision their research agenda advancing crisis informatics research in the LIS community. Then, they will engage in an interactive Q&A with the audience to discuss the current state of crisis informatics research and their prospective plans for advancing the field within the LIS research and practice community. The panel will foster collaborations and contribute to the improvement of response planning and policies through evidence about how information is sought, processed, and used during crises. This panel is sponsored by SIG Social Media (SIG SM).

EP.04A.12 Exploring Rural Appalachian Community Perceptions and Practices on Health and Lung Cancer to Inform Screening Interventions

EP.04A.12 Exploring Rural Appalachian Community Perceptions and Practices on Health and Lung Cancer to Inform Screening Interventions

Influence of a community practice innovation on a statewide cancer drug repository network.

115 Background: Cancer drug repositories (CDRs) have the potential to minimize cancer medication waste while improving medication access to patients in need. Despite multiple states having legislation allowing for CDR programs, implementation remains suboptimal. The first CDRs to launch in Michigan were a fortuitous result of the support provided in embedding clinical pharmacists into community oncology practices via the Pharmacists Optimizing Oncology Care Excellence in Michigan, POEM, program. We describe these grassroot efforts as well as barriers to sustainability, ultimately resulting in formation of a statewide CDR Network, YesRx. Methods: This qualitative analysis of barriers and facilitators was conducted from interviews with Michigan’s first CDRs. Virtual group meetings were conducted monthly for 6-months from January 2023 – June 2023. Meetings were led by the coordinating center team of POEM. Workgroup attendees included POEM pharmacists who established the first 3 CDR programs in the State, a medical oncologist and longstanding advocate of CDRs, and a patient representative. Brainstorming sessions included open ended questions on experiences to date, benefits of CDR programs, barriers to growth, limitations in current CDR models, and beneficial areas for support. Interview findings were categorized as barriers or facilitators of site-specific implementation and recommendations for CDR model optimization. Results: All 3 CDRs reported positive outcomes from initiating the CDRs related to patient benefit and physician satisfaction. Items reported as challenges/barriers in the sustainability of individual site-managed CDRs: space (inventory growth exceeded designated storage capacity), complexity of inventory tracking, resources (staff and financial), inability to search state-wide for available inventory, inability to easily transfer medications between CDR sites (due to cost, documentation, and staff), inability to ship medications directly to a patient’s home, inability to serve cancer patients across the State who may be in need of medication or interested in donating. The top recommendations for CDR model optimization formed by this workgroup were a centralized, shared database of CDR inventory across the State, support for CDR medication transfers, and additional resource and storage capabilities. YesRx, a nonprofit service organization, was founded in July 2023 in collaboration with the first 3 CDRs to address the experienced barriers resulting in exponential state-wide access. Conclusions: Grassroot efforts of community-based clinical oncology pharmacists resulted in the first CDR programs in Michigan and their experiences guided the launch of a statewide network of CDRs created to expand cancer medication access for vulnerable and underserved people and communities.

Provider Perspectives: Feasibility, Acceptability, and Appropriateness of Online Parent Training With Therapist Coaching in a Community Practice Setting

A considerable body of evidence documents the detrimental impact of disruptive behavior disorders (DBDs) in childhood and their longstanding effects across development and into adulthood. While research has yielded evidence-based interventions for DBDs, such as parent management training, disparities in access to care persist. The growing ubiquity of consumer technologies underscores the potential to provide evidence-based treatments through online programs; however, structural barriers continue to impede dissemination in community settings. This paper examines clinic staff’s perspectives on the implementation of an online parent management program in a community mental health center (CMHC) to integrate novel programming with existing therapeutic care to maximize resource efficiency in treatment delivery and increase family adherence and engagement. Quantitative and qualitative data were collected from 16 staff members who were trained to deliver the intervention at a CMHC. Quantitative data indicated positive perceptions across various domains, while qualitative findings highlighted feasibility, acceptability, and appropriateness. Facilitators to feasibility included program ease, integration into sessions, and flexible access. Time constraints and technology access were barriers. Acceptability was high, with videos reinforcing therapy and promoting family connection. The program’s structure and psychoeducation were appreciated, while quiz format and time constraints were concerns. Appropriateness was positive, with broad relevance, insight-building impact, comprehensive coverage, evidence-based strategies, and support. Barriers existed for specific patient characteristics. Implications for implementation in practice and future directions of research are discussed.

Skin Biopsies and Diagnostic Outcomes at a Multisite Family Medicine Residency Network.

Physicians other than dermatologists evaluate nearly 60% of all skin diseases, and 22% of these physicians are family physicians. Dermatology education is therefore an important aspect of Family Medicine training. Dermatologic procedural training in Family Medicine residency is not standardized, however, so family physicians graduate with highly variable skills. This study describes the scope and diagnostic outcomes of skin biopsies performed by residents at a multisite Family Medicine residency network in comparison with those performed by attendings at a Family Medicine faculty community practice. We performed a retrospective chart review of patients evaluated at eight Family Medicine residency training sites and one Family Medicine faculty community practice within a regional academic health system between January 2020 and October 2022. Patients with a skin finding who underwent at least one skin biopsy during their visit were included in the study. Among all of the skin findings, the incidence of skin biopsy was 3.6% (258/7104) for residents and 1.8% (175/9917) for attendings (P < 0.001). Family Medicine residents performed fewer shave biopsies (57.8% vs 77.7%, P < 0.001) and more punch biopsies (25.6% vs 11.4%, P < 0.001) compared with attendings. Most biopsies performed by residents and attendings were benign, although residents biopsied significantly more benign (79.1% vs 64.6%, P < 0.001) and malignant lesions (11.2% vs 5.7%, P = 0.049). Attendings biopsied significantly more low-to-moderate-grade dysplastic (22.3% vs 5.0%, P < 0.001) and high-grade atypical lesions (4.0% vs 0.8%, P = 0.034). Family Medicine residents at this residency network receive training in a variety of skin biopsy types. Distinct skin biopsy practices and outcomes between residents and attendings may reflect differences in patient populations, clinical expertise, and dermatology referral patterns.