Editors



Current Editors: Alekhya Gurram and Jun Park

(Please email editors if there is blog-worthy news that you would like to see shared)

Past Editors: Madelyn Schmidt, Jane Onyemachi, Fareen Momin, Andrea Francis, Renat Ahatov, Michael Phan, Elise Weisert, Michael Ryan, Keith Wagner, Tim Allen, Kristyna Gleghorn, Dung Mac, Alex Acosta, William Tausend, Sheila Jalalat, Rebecca Philips, Chelsea Altinger, Lindsey Hunter, Alison Wiesenthal, Leslie Scroggins, Mara Dacso, Ashley Group, Fadi Constantine, Emily Fridlington, Joslyn Witherspoon, Tasneem Poonawalla.

Monday, May 10, 2010

MS4 Audra Clos Presents Her Research at Cancer Day

Award winning UTMB MS4 Audra Clos will be presenting her interesting research poster, “Relevance of protein misfolding in cutaneous diseases” at UTMB’s Cancer Center Day on Tuesday, May 18th in Levin Hall. Please plan on viewing her poster. Her coauthors on this research are dermatology resident Dr. Matt Petitt and dermatology faculty Drs. Brent Kelly, Richard Wagner and Michael Wilkerson.

Friday, May 07, 2010

Congratulations Dr. Tatiana Sousa!

The UTMB DIG has learned that Dr. Sousa, a former UTMB DIG member (UTMB SOM Class of 2009) and current UTMB PGY1 resident, has accepted a PGY2 dermatology residency position in July 2010 at Case Western Reserve-Metro Health Center in Cleveland, Ohio. The UTMB DIG congratulates you on this wonderful professional accomplishment!

UTMB DIG 2010 Awards for Dermatology Chief Resident and Faculty Teaching


Each year the UTMB DIG selects a PGY4 dermatology resident and one of the dermatology faculty for our annual teaching award. This year the awardees were Drs. Julie Fridlington (resident) and Richard Wagner (faculty). UTMB-Galveston DIG Co-President for 2009-10, MS4 Jarad Levin, presented the awards this year at Friday’s dermatology journal club. Congratulations on your recognition for excellent dermatology teaching this academic year!

Dermatology Chief Resident Publishes Mohs Research

Dr. Ryan Matherne, one of the current UTMB Chief Residents in dermatology, has published his dermatology scholarly project research in Skin Cancer (2010:25:7-10). The title of the article is: "Predictors of patient wound repair satisfaction following Mohs surgery for nonmelanoma skin cancers." His coauthors on this research were UTMB MS3 Michaela Marek, Tatsuo Uchida (UTMB Office of Biostatistics) and Dr. Richard Wagner (UTMB Dermatology). Dr. Matherne will be one of the 2010-2011 UTMB dermatopathology fellows for the upcoming academic year. He presented his original research project to the UTMB Dermatology Department on April 9, 2010.

Thursday, May 06, 2010

Advice for the Away Dermatology Rotation

It’s almost the beginning of the 2010—2011 academic year, and new MS4s across the country who are hopeful about a dermatology career will be taking dermatology electives away from their home schools. Those doing so will probably learn a lot and broaden their educational horizons by visiting different programs across the country or even in the same city, state or region. What distinguishes a good dermatology student from a great one during an away “audition” rotation in the eyes of the faculty, residents, and staff? We polled several dermatology residents and faculty, and came up with the following:

-An excellent dermatology rotator arrives on time in the morning, dresses appropriately, and stays until the last patient is seen in the afternoon clinics. If it is necessary to be absent from any clinic assignment, lecture or rotation, the excellent rotator will let the impacted resident and faculty know about it as soon as is possible.

-An excellent dermatology rotator works hard during the rotation to learn the most possible, including reading about patients seen in the clinic.

-An excellent dermatology rotator shows genuine interest and enthusiasm for dermatology by asking dermatology residents and faculty good questions at appropriate times.

-If an opportunity for research during the rotation becomes available (most often a case report unless the rotation is a planned research elective), the excellent dermatology rotator will volunteer to help research the related medical literature, take the initiative to write up the case and diligently work with the resident and/or faculty, trying to complete the project prior to the end of the rotation or shortly after it. This is a great opportunity for rotators to learn and to create an excellent impression if your interactions, quality and timing of this effort consistently exceed expectations. Be careful not to become too overextended with multiple projects if you don’t think it is possible to complete them in a timely manner with high quality. Faculty and residents understand that no one student can participate in every research idea during a short clinical rotation, and would prefer to see you excel with one project rather than underperform with many.

-An excellent dermatology rotator will avoid drama during all interactions with residents, faculty and staff. Remain professional and positive at all times!

-Past academic performance still counts. Many programs are looking for applicants who have evidenced high academic achievement (high step scores, AOA, published research) but the “perfect” application is rarely achieved. However, the away rotation is an opportunity to create a great first impression that is not possible through impersonal electronic applications. In rare instances, there is nobody applying from a medical school that offers a dermatology residency, so that program must select outside applicants to fill their available position(s). Several dermatology residency programs are not affiliated with a medical school or not closely tied to one in the same city, so they always have to fill with outside applicants.

-If you do well during an away rotation, request a letter from the faculty you worked most closely with, especially if there was research involved. Even if you do not match at that program, the dermatology community is small and that letter may open doors at other programs that are familiar with the writer.

Good luck from the UTMB DIG in your upcoming away dermatology rotations!

Wednesday, May 05, 2010

AAD Poster Abstracts Due by June 4th

UTMB DIG members are encouraged to submit their current dermatology research for consideration as a poster at the upcoming 69th Annual American Academy of Dermatology (AAD) meeting in New Orleans (February 4-8, 2011). If interested, please go to this AAD website for additional information: https://secure.aad.org/PosterAbstracts/

UTMB medical students who have presented dermatology posters in the past at the AAD Annual Meeting have greatly enjoyed this educational experience.

Tuesday, May 04, 2010

Doug Heiner’s Poster Accepted at AAD Summer Academy Meeting in Chicago

DIG member UTMB MS4 Doug Heiner recently learned that his poster entitled, “Preventing ultraviolet light scalp injury: Scalp cancer awareness and protective behaviors” has been accepted for presentation at the Summer American Academy of Dermatology (AAD) meeting this August. His three UTMB coauthors are MS2 Donnie Warren, Mr. Tatsuo Uchida (Office of Biostatistics) and Dr. Richard Wagner. The poster is listed as “P2003” on page 87 of the Scientific Program under “Poster Exhibits” in the Non-melanoma Skin Cancer” category. Congratulations to Doug for this national professional achievement.

Mike Rains Presents UTMB Dermatology Research Honors Thesis

Mike Rains will present his UTMB Dermatology Research Honors Thesis, “Preventing Ultraviolet Light Ear Injury: Ear Cancer Awareness and Protective Behaviors” on Monday, May 10th in the Dermatology Conference Room (4.112 McCullough Bldg). His dermatology faculty mentor on this research was Richard Wagner, MD. His is the 3rd competed Dermatology Research Honors Thesis to be presented from the UTMB SOM Class of 2010. All DIG members, especially those who are interested in participating in the UTMB Dermatology Research Honors Program, are urged to attend in order to become more familiar with the process and to see how a thesis is formally presented, in addition to learning more about ear cancer.

Two UTMB Residents Awarded at Texas Dermatological Society 2010 Annual Spring Meeting

DIG congratulations go out to PGY3 Dermatology Resident Mika Yamazaki and PGY2 Dermatology Resident Neda Nostrati for their recent poster awards in Fort Worth last week. Dr. Yamazaki’s poster, “Capecitabine-induced cutaneous lupus erythematosus and palmo-plantar erythrodysethesia” was awarded 1st place by the judges. Her coauthors on the poster were DIG member MS4 Alison Wiesenthal, PGY4 UTMB Dermatology Resident Dr. Ryan Matherne and dermatology faculty, Dr. Bernard Gibson. Dr. Nostrati’s poster, “Disseminated mycobacteria haemophilum histologically mimicking multibacillary Hansen’s disease in an immunocompromised host” received third place. There were 12 poster abstracts submitted by Texas physicians currently in Texas dermatology residency programs.

MS4 Audra Clos Awarded UTMB Graduation Award

The DIG was pleased to learn that UTMB MS4 and DIG member Audra Clos has been selected to receive the 2010 Dean’s Award for Research Excellence for her groundbreaking work in experimental cutaneous amyloidosis. Following graduation she will stay at UTMB for her PGY1 Preliminary Year in Internal Medicine. The UTMB DIG congratulates Audra on this great professional accomplishment!

MS4 Doug Heiner to Receive Two UTMB Graduation Awards for Dermatology Research

Senior UTMB medical student and DIG member Doug Heiner has been awarded both the 2010 Elias Hochman Research Award and the 2010 Joseph B. Kass Award for Research for his original epidemiologic work on scalp cancer that was conducted on Galveston beachfront last year. His dermatology faculty advisor on this work was Dr. Richard Wagner. Dr. Heiner will begin dermatology residency at Roger Williams Medical center (Providence, RI) in 2011 following a transitional PGY1 year in Spokane, WA at Sacred Heart Medical Center. Congratulations, Doug on your research accomplishments at UTMB!

Monday, April 26, 2010

2010 Society for Investigative Dermatology Annual Meeting

DIG would like to congratulate DIG members Audra Clos (MS4), Lindsey Hunter (MS3), and Michaela Marek (MS3) for having their abstracts accepted to the 70th SID Annual Meeting! Links to their published abstracts can be found below. This year's meeting will be held at the Hilton Atlanta Hotel, May 5-8, 2010 in Atlanta, Georgia. More information can be found at sidnet.org.

Audra Clos:
Coauthors: C. Lasagna-Reeves, R. Wagner, M. Pettit, B. Kelly, M. Wilkerson, G. Jackson, R. Kayed
Title: Therapeutic removal of amyloid deposits by anti amyloid antibodies

Lindsey Hunter:
Coauthors: S. Wang, J. Wickliffe, M. Wilkerson
Title: Photoactivated Rose Bengal, a possible mutagen in Chinese hamster ovary cells

Michaela Marek:
Coauthors: S. Wang, L. Hunter, J. Laster, M. Wilkerson, J. Wickliffe
Title: Chronic exposure to nanosized titanium dioxide negatively effects DNA replication

Saturday, April 24, 2010

The NSRF Best Poster Presentation in Dermatology goes to...

The Best Poster Presentation in Dermatology, sponsored by the UTMB Department of Dermatology, was awarded to Ashley Antony from Johns Hopkins School of Medicine. Her poster title was: TRACKING ACNE LESIONS LEADING TO SCAR FORMATION WITH COMPUTER-ASSISTED ALIGNED PHOTOGRAPHS. The UTMB DIG would like to congratulate Ashley Antony, all of the NSRF award recipients, and all of the NSRF participants for this year's impressive poster and oral presentations. Keep up the good work!

Thursday, April 22, 2010

How I Earned Graduation Credits and Learned Dermatology During UTMB Vacation Periods

One of the best kept secrets at UTMB is that our medical students are often able to earn credits toward graduation during vacation periods. At UTMB our academic year never really ends, because academic credit is available during all Periods, even Period 13 (Winter Break). Many first year medical students earn research credits during the summer break between the first and second year of medical school through participation in the MSSRP. Other first year medical students gain exposure to clinical dermatology early and earn credit by taking DERU-1050 during Periods 1 and 2 between their first and second years of medical school.

MS3 and MS4 students may take a variety of interesting dermatology courses over the Period 13 Winter Break, like Dr. Wagner’s DERU-4007 elective film course that permits teleconferencing from any off-campus location, or a dermatology literature elective (DERU-4011), or the History of Dermatology course (DERU-4008). The DERU-4007 film course now permits registration of 15 medical students each Period.

Wednesday, April 21, 2010

UTMB DIG Members Present at NSRF on Thursday, April 22 from 1 - 3 PM

Several UTMB DIG members (MS4s Audra Clos and Doug Heiner, MS3s Lindsey Hunter and Michaela Marek, and MS2 Donnie Warren) are presenting their research tomorrow at the 51st Annual National Student Research Forum (NSRF) in Galveston. Please stop by Levin Hall from 1-3 PM and see what they have been working on!

Tuesday, April 20, 2010

Dr. Richard Wagner quoted in the Los Angeles Times!

UTMB DIG's faculty advisor, Dr. Richard Wagner, was quoted in the April 20, 2010 Los Angeles Times article, "Indoor Tanning May Be Addictive," which was also mentioned in the UTMB News Highlights today!

"Evidence that tanning is addictive could explain why people ignore well-known health admonitions to avoid excess UV light, said Dr. Richard Wagner Jr., a dermatology professor at UTMB and the lead author of a 2005 study published in the Archives of Dermatology that found similar rates of tanning addiction among beachgoers. 'A lot of times, these people don’t really want to hear that tanning may be a problem,' he said. 'I hear this a lot from my skin-cancer patients. They are sort of in denial.'"

To read the full story, click on the following link: http://www.latimes.com/news/science/la-sci-0420-tanning-20100420,0,1033508.story.

Monday, April 19, 2010

Majority of Dermatology Residency Positions go to US MS4s

According to statistics published by Skin & Allergy News (April 2010, page 2), U.S. MS4s filled 82% of available PGY2 dermatology residency slots in 2010. This trend has been increasing since 2006.

Present Your Student Research At UTMB’s Cancer Center Day

The abstract deadline for Cancer Center Day poster presentations has been extended to next Friday, April 30th. Please contact Laura Koppe (lakoppe@utmb.edu) for additional information. The program is scheduled for Tuesday, May 18th, from 9 am to 3 pm in the Levin Hall Foyer. The best posters will be awarded travel awards of $750 for 1st place and $500 for 2nd place.

Sunday, April 18, 2010

AIM for a Cure Melanoma Walk a success!


This past Saturday, April 17th, DIG held the annual Galveston AIM for a Cure Melanoma Walk at the UTMB Alumni Field House track. Over $1400 was raised for melanoma research and awareness! Special thanks to the melanoma survivor who participated in the walk with her family, and shared her courageous and inspirational story with us.

Thanks to everyone for making this a successful event!

Friday, April 16, 2010

Alison Wiesenthal Published in Spring 2010 Pharos AOA Journal


Check out the Spring 2010 edition of The Pharos of Alpha Omega Alpha Medical Society for Alison Wiesenthal's article, "Death on Call." Congratulations, Alison!

Dr. Julie Fridlington Debuts Mohs Surgery Film

Congratulations to dermatology co-chief resident, Dr. Julie Fridlington, for her film debut about Mohs surgery this week at the weekly dermatology journal club meeting. This presentation fulfilled her dermatology program requirement for a scholarly project. The film is intended as an educational aid for patients considering Mohs surgery for the treatment of nonmelanoma skin cancer. Her dermatology co-resident, Dr. Mika Yamazaki, provided the musical sound track (and the red carpet) for this production.

Wednesday, April 14, 2010

Dr. John Stephens Recognized

PGY3 dermatology resident Dr. John Stephens was recognized by the UTMB Graduate Medical Education Committee for his excellent work during the 2009-2010 academic year. Nominees for the annual UTMB Outstanding Overall Resident/Fellow Award are selected based on evaluation of three categories: Performance in Residency (six clinical competencies, teaching and research), Service to the University (University Committees, Departmental Committees and House Staff Associations) and Service to the Community (volunteer clinical work, local or county medical society, and state or national medical organizations). The UTMB DIG congratulates Dr. Stephens for this well deserved recognition!

Tuesday, April 13, 2010

Dr. Matt Petitt Selected

Congratulations to Dr. Matt Petitt, one of the PGY3 UTMB dermatology residents! Dr. Petitt was selected to attend the Resident Retreat for Future Academicians at the Annual Society for Investigative Dermatology (SID) 2010 Meeting in Atlanta, Georgia this May. According to the SID, this program was started in 2001 “…in an attempt to attract and retain young physicians in physician-scientist, physician/health services research careers and dermatology education.”

Monday, April 12, 2010

DIG Meeting Recap - 4/12

Congratulations to the new 2010-2011 DIG Officers!

2010-2011 Officers:
Galveston President: Lindsey Hunter
Austin President: Melissa Efron
Vice President: Rebecca Philips
Fundraising Chairs: Janese Laster & Erica Snook
Community Outreach Chairs: Michaela Marek & Kristopher McCall
Miles for Melanoma Chairs: Auris Huen & Kenne Ogunmakin

Saturday, April 17th:
DIG is hosting the AIM for a Cure Melanoma Walk at the UTMB Alumni Fieldhouse Track. Registration begins at 9 AM. There's still time to join in on the fun! To sign up, visit: http://www.aimatmelanoma.org/aim-for-action/1158/1159/1167.html, and then click on the "Registration" tab. Questions? Contact Janese Laster (jslaster@utmb.edu) or Douglas Heiner (djheiner@utmb.edu).

Saturday, May 15th:
DIG will be volunteering at the skin cancer screening at the new Bay Colony clinic from 10-1 PM and at the Stewart Road Family Health clinic from 10 - 12 PM.

Directions:
Bay Colony
2785 Gulf Freeway South, Suite 165
(next to 24 Hour Fitness at I-45 and FM 646)

Stewart Road Family Health
6710 Stewart Road, Galveston, TX

We also discussed holding a suturing workshop, fundraising ideas, and voted on faculty and resident awards (results to follow).

To sign up for any of the above events, please contact Lindsey Hunter at lihunter@utmb.edu.

Sunday, April 11, 2010

Dr. Maria Colome Returns to UTMB Dermatopathology Review Course


Attendees at the 11th Annual UTMB Dermatopathology Review Course on Saturday were treated to a lecture by Maria Colome, MD, an internationally recognized dermatopathologist and expert on the diagnosis of pigmented lesions. Dr. Colome initiated this board review course course while she was on the UTMB Dermatology Department faculty eleven years ago. She is currently on the UT Houston Dermatology faculty, and it is always a pleasure to have her return to Galveston. Here she is photographed with Dr. Brent Kelly, Dermatopathology Chief in the Department of Dermatology at UTMB. Dr. Kelly is also an excellent teacher who has won numerous teaching awards from UTMB medical students and dermatology residents.

Thursday, April 08, 2010

UTMB Financially Successful

Galveston Daily News reporter Laura Elder wrote that UTMB was $12.2 in the black for the current fiscal year. More details are available from the article http://www.galvestondailynews.com/story/154654. This is a big improvement since Hurricane Ike damage to the campus in 2008.

Wednesday, April 07, 2010

Congratulations to Dr. Tatiana Sousa!

Dr. Sousa, a UTMB SOM graduate in 2009 and current UTMB PGY1 Internal Medicine Resident, has accepted the Dermatology Clinical Research Fellowship at Columbia University, starting in July 2010. Congratulations on this wonderful achievement!

Next DIG Meeting on 4/12

Our next DIG meeting will be on Monday, April 12, 2010 in the Dermatology Conference Room, McCullough 4.112, at 5:00 PM. We will be voting on awards for residents and faculty, discussing upcoming DIG events, and we will also be holding DIG officer elections for next year.


If you would like to join the meeting but are not in Galveston, please contact Lindsey Hunter at lihunter@utmb.edu.


See you next week!

Monday, April 05, 2010

Congratulations to new Austin DIG President

Congratulations to rising MSIV Melissa Efron, our new Austin DIG President.

Have a great year!

Friday, April 02, 2010

Former UTMB Students Return to UTMB Dermatology for Grand Rounds


At our weekly Friday Dermatology Grand Rounds, Dr. Dayna Diven (Top photo - far right, teleconferencing from Austin) and Dr. Conner Chan (Bottom photo - sitting next to his former UTMB classmate, Dr. Ashley Group, in the UTMB Galveston Dermatology Conference Room) participated. UT Southwestern-Austin Dermatology residents, where Dr. Diven is the Program Director, presented dermatology patients for group discussion. Dr. Chan is currently a PGY2 dermatology resident at LSU. The first UTMB medical student to match at the new UT Southwestern Dermatology Residency Program, Mike Rains, will join them as a PGY2 resident in 2011.

Wednesday, March 31, 2010

Austin DIG Elections 4-5-10

Attention all full-time Austin medical students!

The UTMB Austin DIG will be holding elections for the following positions next MONDAY:

Austin DIG President

Austin DIG Stay Shady! Representative

If you are interested in either of these positions, e-mail Alison at acwiesen@utmb.edu.

Tuesday, March 30, 2010

Learn More About Dermatopathology From the Experts!

Save the weekend of April 10th and 11th, for the 11th Annual UTMB Dermatopathology Review Course. For further information please see the website: http://www.utmb.edu/dermatology/dermatopathology/Dermatopathology%20Review%20Course.html and the course brochure: http://www.utmb.edu/dermatology/pdf_ads/Derm_path_2010_Brochure.pdf
Please note that the course will be held in Levin Hall, and not at the School of Allied Health Sciences and Nursing Building as described in the brochure.

Evaluation Criteria for UTMB Dermatology Honors Research Thesis

Many students interested in the UTMB Honors Research Program wonder how their research is evaluated. How does the ad hoc thesis committee evaluate Dermatology Honors Program Research? The committee looks at multiple factors, such as:

-Was the hypothesis (proposal question, idea) generated by the student with little or no faculty involvement?

-Is the study confirming the results of a previous study, or is it addressing questions not answered by previous studies?

-What is the impact of the study on the area of research?

-What new and novel findings were generated by the study?

-Can or has the study been published in a high impact journal?

-How well presented are the results of the study (both written and oral)?

-Does the student have an in-depth understanding of the research area?

Thank you, Dr. Simon Lewis, for providing this information.

Monday, March 29, 2010

Magna Cum Laude Graduation Honors

Congratulations to MS4 Doug Heiner for his successful defense of his UTMB Dermatology Research Honors Thesis entitled, "Preventing Ultraviolet Light Scalp Injury: Scalp Cancer Awareness and Protective Behaviors."

His dermatology faculty thesis advisor was Dr. Richard Wagner, and his dermatology ad hoc thesis committee faculty were Dr. Sharon Raimer and Dr. Brent Kelly. The UTMB DIG congratulates you for a job well done!

Saturday, March 27, 2010

Don't Miss This!

Please remember to see UTMB MS4 Douglas Heiner present his award winning dermatology research at his honors thesis presentation entitled, "Preventing Ultraviolet Light Scalp Injury: Scalp Cancer Awareness and Protective Behaviors" on Monday afternoon, March 29, 2010 at 4 pm in the dermatology conference room (4.130 McCullough Building).

Tuesday, March 23, 2010

Thank You from Odyssey Academy



I received a lovely thank you note from Odyssey Academy this week thanking us for our work with Stay Shady! Thank you to all our wonderful volunteers and sponsors who have made this community outreach such a great success.


Regards,

Alison Wiesenthal
DIG Co-President


Thursday, March 18, 2010

UTMB DIG Congratulates UTMB Dermatology "Class of 2014"

The results of the 2010 NRMP were made official on March 18th, and the UTMB Department of Dermatology learned that they matched with (alphabetical):

Jason Jones (Texas Tech University HSC SOM, Class of 2010)

Megan Moody (UT Medical School Houston, Class of 2009, Fellowship with Leonard Goldberg, MD, planned for 2010-2011)

Samantha Robare-Stout (Loma Linda University School of Medicine, Class of 2010)

All Texans! This was the first time in 10 years (Class of 2004) that UTMB did not match with at least one of their own medical students. No one matching at UTMB Dermatology today had done a previous "away" rotation in Galveston.

Congratulations! You have matched into a great dermatology residency program! We all look forward to working with you in the future!

UTMB MS4s with 2010 NRMP Dermatology Matches

Douglas Heiner: Roger Williams Medical Center, Providence, RI

Julie Nguyen: University of Oklahoma College of Medicine, Oklahoma City, OK

Mike Rains: University of Texas Southwestern Medical Ctr, Austin, TX


Congratulations from the UTMB DIG on your great success! We are very happy for you! Here is the UTMB Class of 2010 match list link:

http://www.utmb.edu/iutmb/pdfs/UTMBMatchDay2010.pdf

Wednesday, March 17, 2010

What I Really Mean (apologies to REK)

What do many dermatology applicants do after finalizing their rank list? Although often officially discouraged by programs, many applicants decide to communicate anyway with them about their decision. Here are some communications the UTMB DIG has uncovered (with our thoughts inside parenthesis):

"I ranked you number one on my match list." (No real ambiguity here.)

"You are my top choice." (Again, little ambiguity.)

"I ranked you at the top of my rank list." (Not really saying very much. If the applicant ranks 10 programs, number 4 is still at the "top").

"You are one of my top three programs." (Signals that this program is not number 1 on your list. Is that what you really wanted to communicate?)

"I really liked your program and would be very happy to match with you." (Harder to interpret. However, not mentioning that the program is your first choice will not be missed.)

"Let's be friends." (Says it all!)

Bottom line: Does what you write to programs really matter? There is still much debate on this issue. Can it help you match? Maybe. Can it hurt? Also a possibility. How the communication is interpreted is very important. Of course the writer has the most control over this.