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Advancing the Science and Art of Teaching Dermatology:  Abstracts Presented at the Ninth Winter Meeting of the Dermatology Teachers Exchange Group, March 21, 1999, New Orleans, La FREE

Ponciano D. Cruz Jr, MD
[+] Author Affiliations

From the Department of Dermatology, University of Texas Southwestern Medical Center, Dallas.

Arch Dermatol. 1999;135(8):967-970. doi:10.1001/archderm.135.8.967.
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The Dermatology Teachers Exchange Group (DTEG) convenes biannually in late winter (February or March), concurrent with the annual meeting of the American Academy of Dermatology, and in the fall (October), concurrent with the meeting of the Association of Professors of Dermatology. At the most recent meeting, which was held March 21, 1999, in New Orleans, La, 10 abstracts were presented on several teaching strategies for dermatology and nondermatology residents, medical students, primary care physicians, and the public-at-large. More than half of the discussion centered on computer technology–driven mechanisms in dermatological education. The DTEG has also conducted workshops, particularly in its fall meetings. The next DTEG meeting on October 1, 1999, will feature a workshop on the process of interviewing applicants for dermatology residency programs.

The DTEG is led by a steering committee including Ponciano D. Cruz, Jr, MD; John E. Olerud, MD; Robert T. Brodell, MD; Janet A. Fairley, MD; Steven E. Wolverton, MD; William D. James, MD; Mary C. Spellman, MD; Lynne H. Morrison, MD; and Jill Crolick, MD. Since its inception, the DTEG has been supported by annual grants from Pharmacia-Upjohn, Kalamazoo, Mich. This year other grant donors included Pfizer, Inc, New York, NY, and Novartis, Cincinnati, Ohio.


Ashish Bhatia, MD, Robert Brodell, MD, Bryan Davis, MD, Department of Dermatology, Case Western Reserve University School of Medicine, Cleveland, Ohio, and Northeastern Ohio University College of Medicine, Rootstown

The field of dermatology includes information that can be learned conceptually and other important knowledge that requires rote memorization. The DERM Project (Dermatology Education by Recall of Mnemonics) was developed to assist the medical student or resident in learning the latter material. We designed and implemented an inexpensive, universally available, user-friendly Web-based application that provides useful mnemonics as well as a test of this information. Teachers will also find it easy to identify useful mnemonics and use them to provide a framework for presenting information.

A preliminary set of 95 dermatologic mnemonics were entered into a database. We chose the database program FileMaker Pro 4.0 (FMP4) because of its cross-platform compatibility and built-in extensions for Web-application design. The Web interface was designed using hypertext markup language (HTML) with FMP4–specific code inserted into the standard HTML document. The initial interface was designed to perform the following 4 basic functions: (1) allow the user to cycle through the available mnemonics, (2) allow the user to search the database for mnemonics for a particular condition, (3) quiz the user on mnemonics in the database, and (4) allow the user to resume a quiz session at the same place where previously he or she had ended.

In addition to these functions, we added a feature to allow a user to submit a new mnemonic to the database administrator. On review of any submissions, the administrator can easily insert the new mnemonic into the master database. We give credit to the individual who submitted each mnemonic. The initial format is designed to allow easy upgrade of the features and functions available to the user. Concepts for enhancement of the basic application include (1) a feature to allow complex searches of the database, (2) the addition of clinical and micrographic images that correlate to the subject of the mnemonic, (3) a table of contents and subject headings for all of the available mnemonics, and (4) incorporation of chapter references to major dermatologic textbooks. The DERM Project may be accessed on the World Wide Web at http://derm.metrohealth.org/dermed/.


Jason Fung, MD, Sophie Worobec, MD, University of Rochester School of Medicine and Dentistry, Rochester, NY

A questionnaire was distributed to first- and fourth-year medical students at the University of Rochester School of Medicine and Dentistry to survey and compare their attitudes, beliefs, and behaviors regarding UV protection.

There were 86 first-year respondents and 88 fourth-year respondents. There was no statistical difference (95% confidence level) between fourth- and first-year students in their ability to identify melanoma and nonmelanoma skin cancer risk factors. Of 8 risk factors common both to melanoma and nonmelanoma skin cancers, fourth-year students significantly left unidentified 4 for nonmelanoma skin cancers while first-year students left 3 unidentified. One of these was high exposure to UV radiation.

Use of sunscreen when outside in the sun correlated with skin type for both fourth- and first-year medical students. Nearly all medical students in both groups would advise patients to protect their skin from UV exposure. Regardless of skin type, nearly all medical students in both groups wore tightly woven clothing and sunglasses on sunny days. Nearly all in both groups were aware that sunscreen use can help reduce the risk of skin cancer.

We conclude that overall attitudes, beliefs, and behaviors regarding UV protection varied little between the 2 groups of medical students. Medical students would probably benefit from learning more about the differences between melanoma and nonmelanoma skin cancers.


Hayes B. Gladstone, MD, Susan Y. Kim, MD, John Bolles, MD, Kristina Rashid, MD, Gregory J. Raugi, MD, Division of Dermatology, University of Washington and Veterans Affairs Medical Center, Seattle, Wash

Medical students at the University of Washington School of Medicine take a comprehensive basic science–oriented skin biology course during their second year. Because fewer than half of our students can take an elective in clinical dermatology, we have traditionally incorporated clinical information on melanoma into the curriculum. Its continued importance has led us to consider innovative ways of teaching the subject. Because the Internet is easy to access and provides the ability to use hypertext and graphics in creative ways that are impossible in lecture or textbook format, we felt that developing a Web site would provide an effective method to teach basic concepts in the biology and clinical recognition of malignant melanoma.

We constructed a Web site that covered the various aspects of melanoma ranging from epidemiology to treatment, but that emphasized the clinical "ABCDs" of teaching about melanoma. We assessed the effectiveness of the Web site in teaching these basic aspects by comparing students' answers on a test taken before and one taken after using the Web site and by studying responses to a questionnaire about the effectiveness of the Web site.

After using the Web site, the students demonstrated significant improvement on the multiple-choice section of the second test. There was also some improvement in rating the malignancy of pigmented lesions after completing the Web site lessons. Importantly, student satsifaction with the Web site as a teaching tool was overwhelmingly positive.

These results show that the Internet can be used effectively to teach a well-defined topic such as melanoma. However, these results also suggest that a Web site with multiple layers of complexity may be an effective teaching tool for medical students and primary care residents throughout their training.


Hayes B. Gladstone, MD, Jeff Berkley, MD, Daniel Berg, MD, Suzanne Weghorst, MD, Gregory J. Raugi, MD, Division of Dermatology, Departments of Medicine, and Human Interface Technology Laboratory, Mechanical Engineering, University of Washington, and Veterans Affairs Medical Center, Seattle, Wash

Graduating medical students should be able to perform simple surgical excisions and repair minor lacerations. Traditionally, students have learned these procedures using pigs' feet and then practicing on patients during surgical, obstetric-gynecological, or emergency department rotations. This educational method is limited by instructor time and ethical considerations. We are developing a skin surgery simulator that circumvents these problems and allows students of varying skill levels to learn, practice, and refine these procedures with the aim of improving patient care.

Surgical simulators are computationally intensive; heretofore, it has not been possible to run a skin surgical simulator in real time on an affordable desktop computer. However, using fast finite element modeling algorithms developed at the University of Washington, we have been able to simulate skin deformation with real-time force feedback using haptic devices and a personal computer.

Currently, our system is able to simulate simple needle puncturing and thread modeling on premade wounds. We will soon have the capability to simulate incisions, undermining, and knot tying—the basic techniques of dermatologic surgical excision. Eventually our system will enable dermatology residents to practice local reconstructive surgery on the head and neck. We will discuss the challenges of developing this simulator as well as our plans for expert validation and testing its efficacy on students.


H. B. Hahn, MD, T. Y. Chuang, MD, C. W. Lewis, MD, S. M. Minick, MD, G. W. Mirowski, MD, E. R. Farmer, MD, Departments of Dermatology and Biostatistics, Indiana University Medical Center, Indianapolis

Purpose: DIDS (stages 0-IV) is a severity-of-disease instrument based on body surface area and functional limitation for inflammatory cutaneous disease. Psychometric studies have been completed. We used DIDS to teach dermatology residents and students about severity of disease.

Method: Fourth-year medical students used DIDS with minimal verbal explanation. Sixty-two patients with psoriasis or dermatitis were each rated by a physician and a medical student. In a separate study, dermatology residents rated patients with inflammatory cutaneous disease using DIDS along with the clinical information.

Results: In the study with medical students, the distribution of DIDS scores for patients with psoriasis or dermatitis was 2 at stage 0, 31 at stage I, 10 at stage II, 16 at stage III, and 3 at stage IV. The medical-student rating agreed exactly with the physician rating 49 of 62 times. This is a 79% exact agreement with a 95% confidence interval of 69% to 89%. Of the 13 disagreements, the medical students always rated the disease more severe than did the physician, 12 times rating the disease 1 stage higher and 1 time rating the disease 2 stages higher. In the second study, residents recorded 740 cases of inflammatory cutaneous disease during 6 months. Seventy-nine of all patients were stage III or IV, indicating moderate to severe disease. Sixty-nine patients had psoriasis. Of these patients, 30 were at stage 0 to I, 24 were stage II, 12 were stage III, and 3 were stage IV. Of interest, 1 patient remained stage III during 6 months, suggesting either a compliance issue or a therapeutic problem.

Conclusion: DIDS is an instrument that is easily used. Medical students used DIDS with minimal instruction, and this further supports its reliability and usability. We used DIDS to instruct medical students and residents about severity of disease and provided a quantifiable method for monitoring patients in dermatology.


William D. James, MD, Jeffrey J. Miller, MD, University of Pennsylvania, Philadelphia

Current educational theory values the concept of cooperative learning where students learn by doing while pooling their knowledge through group interactions. It is known that 40% of new material that is presented verbally is retained, while more than 90% of ideas learned by doing are internalized. The teacher in this situation acts as a facilitator, encouraging interchange and ensuring that everyone is involved in the problem-solving process.

At the 1998 American Academy of Dermatology meeting, the 24 participants in the discussion session on difficult consultative cases were divided into 6 groups of 4 each. Everyone was given a job; each group was asked to solve 3 consultative cases. At the end of the problem-solving portion of the session, each group selected a case for presentation to all the participants. This was followed by feedback from the moderator regarding the real-life results of diagnostic tests and treatment. Participant evaluation resulted in scores greater than 2 SDs above the mean. Active learning in small groups is an applicable strategy for dermatology teachers and leads to enthusiastic learners.


Toby A. Maurer, MD, Timothy G. Berger, MD, Barbara Gerbert, MD, Amy Bronstone, MD, Karen Maffei, MD, Roger Hofmann, MD, Departments of Dermatology, Behavioral Science, University of California, San Francisco, and West Portal Software, San Francisco

Decision-support software was developed to help primary care physicians arrive at triage plans for nonmelanoma skin cancers. The software allowed for solicited clinical information to automatically be imported into a decision tree. The objective was to determine whether primary care physicians using this tool could better triage skin cancers than those physicians not using this tool. Twenty primary care physicians were tested on 30 digitized images, using the tool and not using the tool. Without the decision-support software, physicians chose the wrong triage decision 37% of the time; with the decision-support software, they chose the wrong response only 13% of the time. Without the decision-support software, physicians failed to either correctly biopsy or identify a cancerous lesion 22% of the time; with the software, they failed to either correctly biopsy or identify a cancerous lesion only 4% of the time. Physicians scored an average of 3 points (of 15) higher when they used the software (signed rank, 101; P<.001). Physicians scored an average of 1 point higher on identifying the 7 cancerous lesions when they used the software (signed rank, 65.5; P<.003). These findings demonstrate the promise for decision-support software to improve primary care physicians' triage decisions for lesions suspicious for nonmelanoma skin cancer and potentially to reduce morbidity and health care cost.


Ginat W. Mirowski, MD, Antoinette F. Hood, MD, Departments of Dermatology, School of Medicine & Oral Surgery Medicine Pathology, School of Dentistry, Indiana University, Indianapolis

Every year, faculty spend a considerable amount of time developing lectures for medical students and students in other health professions. However the traditional lecture format may not be suitable for all students, particularly if the students are visually focused or if they are located at great distances from the lecture site.

This past year, 2 sophisticated Web-based dermatology modules were developed in parallel (one at the School of Medicine and the other at the School of Dentistry). WebCT (a World Wide Web Course Tools software developed by the University of British Columbia, Vancouver) helped facilitate the creation of a secured, but interactive, online teaching tool that permitted access to the course for both the course author-designer and the students from any networked computer. All the students needed to access the program were a computer and a password.

In addition to providing course-specific lecture notes, a large image library, and a laboratory session, we were able to give the students direct linkage to other relevant teaching sites on the World Wide Web. The program allowed us to track individual students' use of the Web pages, to give self-assessment quizzes, and to administer tests and grades electronically.

WebCT was easy to learn, fun to work with, and saved many administrative hours. The students found that they could study the information at their own convenience and as many times as necessary. Most importantly, the classroom was always open to them, day or night, 24 hours a day. We believe that Web-based courses increase the accessibility and interest of students to the specialty of dermatology.


R. Stan Taylor, MD, Department of Dermatology, University of Texas Southwestern Medical Center, Dallas

In addition to fulfilling the Residency Review Committee's requirements for surgical training of dermatology residents, we have developed a formal curriculum that attempts to provide a broader educational experience, touching on traditional as well as emerging techniques used by dermatologic surgeons in clinical practice. The foundation of the training program is a weekly didactic session that incorporates lectures, demonstrations, and practice sessions and follows a series of topics with reading assignments. Knowledge and skills are practiced and applied weekly in a number of surgical clinics and monthly rotations with dermatologic surgeons and plastic surgeons. Instruction is provided by 1 full-time academic dermatologic surgeon, members of the Department of Plastic Surgery, and a dozen clinical faculty recruited from the private-practice community. Acquisition of knowledge and skills is evaluated quarterly with a written examination and biannually by observation in the clinic and an interview with the course director. Residents have been pleased with the program, and progress in surgical skills development can be monitored and guidance tailored for individual residents. Formal training of the residents in surgical procedures is critical if graduates are expected to perform safe and appropriate procedures once in practice. The key factors to successful training include a well-organized educational program, supervised clinical sessions, an effective means of determining if residents are acquiring skills and can use them appropriately, and productive, collaborative relationships with members of the private-practice community to assist limited full-time faculty resources.


Karen Edison Zanol, MD, Division of Dermatology, Department of Internal Medicine, University of Missouri, Columbia

To address the need for innovation in education in dermatology, we are using problem-based learning to teach dermatology to medical students and dermatology residents and to allow practicing physicians to earn continuing medical education credits. This type of innovation is needed to help learners of dermatology to think critically and analyze and solve complex problems; to find, evaluate, and use appropriate learning resources; to work cooperatively in teams; to demonstrate effective verbal and written communication skills; and to use content knowledge and intellectual skills to become lifelong learners. Problem-based learning in dermatology has been well received by students of all types and these surveys and methods are presented, along with data showing dramatic improvements of our medical students on national board examinations. Problem-based learning is a teaching method that can be effectively used to teach dermatology. As DTEG members, we should join together to create a set of problem-based learning cases that we can share over time.

Reprints: Ponciano D. Cruz, Jr, MD, Department of Dermatology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75235-9069 (e-mail: pcmz@mednet.swmed.edu).

Introduction by Ponciano D. Cruz, Jr, MD

Accepted for publication April 20, 1999.





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