Dermatology undergraduate skin cancer training: a disconnect between recommendations, clinical exposure and competence

Abstract

BackgroundSkin cancers are the most common malignancies in Caucasian populations. Non-specialists are responsible for the initial assessment of skin lesions and are required to act as the gatekeepers to dermatological cancer services in many healthcare systems. The majority of such physicians receive very limited formal undergraduate or postgraduate dermatology training. The British Association of Dermatologists (BAD) has produced guidelines that list the lesions that students should be able to diagnose on graduation and the majority of UK medical schools’ operate curricula in keeping with these. There is, however, virtually no evidence as to whether these competencies are being achieved. We set out to determine students’ competence at skin lesion diagnosis and to quantify their clinical exposure to examples of such lesions during their dermatology attachment.MethodsThree linked studies were undertaken. In the first, students’ competence was tested by randomized slideshows of images containing the 16 lesions recommended in the UK guidelines. Students’ accuracy was tested at the beginning (Day 1) and end (Day 10) of their clinical placement, with a random sample of students retested 12 months later. Secondly, students’ exposure to these lesions was recorded during their attachments. Finally a survey of the additional dermatological resources used by the students was undertaken.ResultsStudy 1: Students’ diagnostic accuracy increased from 11% on Day 1 to 33% on Day 10 (effect size +2.72). After 12 months half of this effect had disappeared and the students accuracy had dropped to 24%. Study 2: Students’ exposure to the recommended lesions was poor with 82% not even witnessing a single example of each of the 3 major skin cancers. Despite these measurements, only a minority of students reported that they were not confident at diagnosing skin tumours. Study 3: The majority of students use additional resources to supplement their learning.ConclusionsIn the light of what we know about learning in dermatology, our data would suggest, that the current (traditional) undergraduate attachment is inadequate to meet the UK recommendations for graduate competence. As well as critically examining the basis for these recommendations, we need more empirical data on student performance and exposure, in order to improve teaching and learning.

Assessment of Smartphone Application for Teaching Intuitive Visual Diagnosis of Melanoma

“…Thus, limited experience is the primary barrier to the development of pattern-recognition and intuition as a reliable tool for melanoma diagnosis in nonexperts. 3 To remedy this problem, we developed a novel web-based application to mimic the training of a dermatologist by teaching medical students intuitive melanoma diagnosis in a highly condensed period of time. Our application, Skinder, teaches intuitive visual diagnosis of melanoma by quickly presenting the learner with thousands of benign and malignant skin lesions.…”

Teaching and Learning in Dermatology: From Gutenberg to Zuckerberg via Way of Von Hebra

“…Most medical schools have carousel structures for attachments such as dermatology. It does not require profound insights into cognitive psychology to know that student performance deteriorates after they finish any single attachment (32). The reasons are not hard to fathom.…”

“…Given the role of NAR in dermatological diagnosis the ability to expose students in a structured way to large volumes of relevant and well annotated images may be a real boon to student learning. For instance, at my own institution, despite considerable investment of time and resource, and with students receiving more than the average undergraduate exposure for the UK, clinical exposure to skin cancers was at such a low level that meaningful clinical skills were unlikely to develop (32). In practice, our students use the free resource provided by the New Zealand dermatology sociefy (http://dermnetnz.org/), or freely available online textbooks that contain more clinical photographs than standard undergraduate dermatology texts (note a conftict of interest: the current author is the author of one of these online texts).…”

“…The idea that 'self-reflection' or some measure of the ability of a student or doctor to be a reflective practitioner provides a worthwhile measure of competence is mistaken. For instance we have recently shown that students who claim certitude about their ability to diagnose skin cancer in the absence of objective evidence should give great concern -particularly if you are a patient with a potential skin cancer (32). "You learn medicine by being an apprentice."…”

Dermatology teaching in Australian medical schools

“…However, evidence evaluating whether these recommendations have been put into practice is limited. 4,5 As a result of this preliminary work, a formal review of current dermatology teaching at the university level is underway. This aims to document the current situation in greater detail and explore additional areas such as student assessment methods.…”