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Implementation of dermato-epidemiology curriculum at Case Western Reserve University dermatology program

  • Author(s): Barzilai, David A, PhD
  • Mikkilineni, Radha, MD
  • Davis, Bryan R, MD
  • Stevens, Seth R, MD
  • Mostow, Eliot N, MD MPH
  • et al.
Main Content

Implementation of dermato-epidemiology curriculum at Case Western Reserve University dermatology program
David A Barzilai PhDa,b, Radha Mikkilineni MD a,d, Bryan R Davis MDa, Seth R Stevens MDa,d Eliot N Mostow MD MPH a,c,dCleveland, Ohio and Akron, Ohio
Dermatology Online Journal 10 (1): 1

From the Department of Dermatologya and the Department of Epidemiology and Biostatistics,b Case Western Reserve University / University Hospitals of Cleveland, Cleveland, Ohio; Department of Medicine, Division of Dermatology, Northeastern Ohio Universities College of Medicine, Akron, Ohio,c Louis Stokes V.A. Medical Center, Cleveland Ohiod. emostow@neoucom.edu

Abstract

Dermato-epidemiology curriculum has been identified by the American Academy of Dermatology (AAD) as an important foundation for dermatology residency training. However, no one has yet reported implementation of dermato-epidemiology curriculum. To evaluate and relate our experience carrying out a dermato-epidemiology resident education initiative, based on recommendations by the AAD Epidemiology Committee. Monthly lectures based on topics suggested by the AAD Epidemiology Curriculum. Pre- and post-test multiple choice and free-form question measures were employed to examine performance, assess resident enthusiasm, and solicit feedback from the initiative. Quantitative achievement on multiple-choice items improved slightly, but insignificantly, from 53 percent to 58 percent. Resident level of enthusiasm and perceived efficacy for the intervention varied from 3.3 to 4.0 on a 5-point Likert scale where "1" indicates strongly disagree and "5" indicates strongly agree with measures of effectiveness. Dermato-epidemiology curriculum is desirable and achievable even in dermatology programs without full-time epidemiologists. A successful epidemiology curriculum should be clinically and board-examination relevant, incorporating aspects of problem-based, interactive learning.



Introduction

In the last few decades, there has been increasing interest in medicine for population-based epidemiological and outcomes research [1] and education [2, 3], including clinical biostatistics and health services research. Part of this has been attributable to a push toward evidence-based medicine in the medical community at large, with growing realization that tradition, experience, common sense, and even sound pathophysiology without verification, often result in unnecessary and even harmful therapy [4]. There has also been an economic impetus for population-based study because of the need to prioritize resources in a healthcare system with vast yet fixed resources. This has resulted in an increased attention to process and structural forces that impact the quality of health care a patient receives. Finally, there has been increasing interest in using epidemiological methods to identify risk factors that would permit public interventions and health campaigns to prevent disease before it arises [5]. Publications are more likely to include tables with p-values, odds ratios and confidence intervals, statements of "quality of life" or assertions of "cost-effectiveness," case-control, cohort, or randomized controlled trial studies and meta-analyses. Epidemiology and its methods have been slowly but steadily appearing in mainstream dermatology.

Increasing enthusiasm for epidemiology in dermatology, represented by such changes as the foundation of the International Dermato-Epidemiology Association (IDEA) in 1996 [6], formation of the Cochrane Skin Group [7], publication of the first textbooks on dermato-epidemiology in 1997 [2, 8], and introduction of the "Evidence-Based Dermatology" section of Archives of Dermatology in 1998, have been encouraging. However early in the third millennium, we are only beginning to tap the potential of dermato-epidemiology as a tool to study cutaneous disease, patterns of care, and outcomes [5]. In a 1999 National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) conference addressing the prospects of epidemiology in dermatology, it was observed that relative to similar fields such as rheumatology, dermatology is far behind in population-based clinical research [9] and health-services outcomes studies being published in the major dermatology journals [10]. Few physicians able to "speak the language" of epidemiology [11].

One potential solution to the dermato-epidemiology research and education gap is to provide exposure to this field during residency training. This could provide an understanding of basic epidemiology and encourage young researchers to consider dermato-epidemiology research [11]. Here we relate our experience with such an intervention at Case Western Reserve University (CWRU).


Methods

To promote resident education, we piloted the American Academy of Dermatology (AAD) dermato-epidemiology curriculum in University Hospitals of Cleveland's Department of Dermatology residency program in fall of 2001.

Goals for the initiative were to:

  • Foster familiarity with basic vocabulary, issues, methods, analysis, and design of epidemiological studies/biostatistics.
  • Cultivate critical evaluation skills in reading the dermatological literature.
  • Provide material that is conceptually oriented and relevant to clinical practice and board examinations preparation.

The pilot course was structured as a monthly lecture series complementing article selections from the AAD Epidemiology Committee curriculum published in 1999 on the Member's Only section of the AAD website and publicly available on the International Dermato-Epidemiology Association (IDEA) website. These selections address basic epidemiological principles. Lecture topics covered at Case Western Dermatology Program were adapted from general curriculum recommends in the AAD curriculum, and included: 1) "Introduction to dermato-epidemiology," 2) "Validity and reliability of screening tests," 3) "Bias in studies and mortality," 4) "Observational studies and measures of risk," 5) "No evidence of effect," 6) "Evidence based medicine in dermatology," 7) "Quality of life studies and categorical statistics," 8) "Systematic reviews," 9) "Confounding," 10) "Health Services Research," and 11) "Randomized controlled trials" (See Appendix).

As one measure to assess the effectiveness of the pilot intervention at CWRU dermatology program, confidential pre-test and post-tests were conducted. The epidemiological multiple-choice questions were adapted from basic epidemiological textbooks. To gauge the level of enthusiasm of residents, supplemental open- and closed-ended questions regarding effectiveness were added to the post-test. General feedback was also solicited.


Results

For the evaluative portion of the test, the five residents (of nine) who took both pre-test and post-test improved performance from 53 to 58 percent. Supplemental questions in the post-test captured the degree of resident interest and resident perception of the intervention. On an ordinal Likert scale where "1" indicates strongly disagree, and "5" indicates strongly agree, residents indicated a mean of 3.8 that "the dermato-epidemiology curriculum was a worthwhile endeavor," 4.0 that the dermato-epidemiology curriculum "has imparted a basic familiarity with the vocabulary, issues, methods, analysis, and design of epidemiological studies," a 3.3 that the dermato-epidemiology curriculum "has helped with understanding and evaluating the dermatological literature," a 3.4 that the dermato-epidemiology curriculum "is helpful for board preparation," and a 3.7 that the dermato-epidemiology curriculum "was clinically relevant."

Free-response comments made by residents included a preference for 1) an interactive discussion approach over a lecture format, 2) more teaching vignettes from the dermatology literature, and 3) use of board-style test questions for problem-based learning.

During the didactic sessions, residents appeared to be engaged with the topics and expressed interest regarding how best to determine the quality of research papers. They focused on interpreting correctly basic biostatistical measures and applying basic epidemiological principles to clinical decisions and patient care.


Discussion

We note that this relatively informal pilot evaluation was prone to selection bias due to incomplete participation and that a more thorough evaluation would require validation of quiz questions. The small and insignificant improvement could be due to inadequate sensitivity of the test questions, too few or too widely-spaced lectures, insufficient external motivation to review materials (residents knew that their performance would remain confidential and not be shared with their instructors), and to inadequacies of the curriculum.

As educators, our area of primary influence is over curriculum content and delivery; we are making changes to improve post-test performance. These include decreasing lecture-hours and increasing the integration of epidemiological principals into the existing journal club to make sessions more interactive and problem based. We are also monitoring which learning objectives have been covered during each annual curriculum cycle. We intend to expand and validate the pre- and post-tests to ensure that they can capture clinically-relevant changes in epidemiology knowledge. We are encouraged, even with this first implementation of the curriculum, that residents feel that the topics covered were "clinically relevant" (3.7/5.0) and "imparted a basic familiarity with the vocabulary, issues, methods, analysis, and design of epidemiological studies" (4.0/5.0).


Figure 1
Figure 1: Dermatology Research Tree. Reproduced with permission from The Challenge of Dermato-epidemiology" edited by Hywel C. Williams and David P. Strachan, CRC Press. P. 14

While traditional cutaneous basic sciences (cellular and molecular biology, histopathology, genetics, and immunology) are taught early in residency, population-based health sciences have traditionally been underrepresented, as depicted by Hywel Willliam's imbalanced "tree of dermatological research" (Fig. 1) [2]. During a recent AAD-sponsored resident retreat for future physician scientists, it was suggested that many young scientists were not even aware of health services research as an academic career option [1]. It is not surprising that so few dermatologists have been pursuing epidemiological research. We believe that early exposure to clinical epidemiology may help address this imbalance and encourage young researchers to follow the research road less traveled.

Epidemiology is an indispensable tool for critical evaluation of the medical literature and the practice of evidence-based medicine [12]. In addition, third party payers are increasingly requiring evidence of treatment efficacy before providing coverage. Prevalence and other measures of disease burden are being used to determine health policy and to allocate health care resources. Dermatologists need a basic understanding of epidemiology and public health to become well-informed participants in national research, practice, and policy debates surrounding health care, lest they be excluded.

The epidemiology curriculum at Case Western Reserve University / University Hospitals of Cleveland has received positive feedback from the residents and faculty as being clinically relevant, thought provoking, and fun. This experiment is part of an ongoing process of curriculum evaluation and change [13], based on a philosophy that dermatology learning and teaching skills can be studied and improved through formal study, training, and practice [14]. Next year's implementation of the epidemiology curriculum will incorporate feedback from residents by integration of core concepts and vocabulary into our traditional reviews of the Archives of Dermatology and the Journal of the American Academy of Dermatology. The Epidemiology Curriculum is not meant solely for programs with epidemiological expertise. Rather, it was designed as a list of didactic and clinical articles for a journal-club format that can be adapted by any program. Integrating all or part of the AAD epidemiology curriculum can be done simply by bringing the recommended papers into an already established journal club.

For readers interested in applying epidemiological principles to answering clinical questions and carrying out evidence-based practice, an Evidence-Based Dermatology web resource was designed by one of the authors (DAB) in concert with the dermato-epidemiology lecture series. This resource also functions as a teaching toolkit, with a brief PowerPoint presentation orienting users to the relevance of various web-based epidemiological and evidence-based dermatology resources. Evidence-Based Dermatology, like the dermato-epidemiology curriculum, is a work in progress, and we welcome comments and suggestions on how it may be improved to better serve the dermato-epidemiology research and education community. We welcome other programs to share their curriculum ideas and results.

Acronyms and Abbreviations: AAD = American Academy of Dermatology. CWRU = Case Western Reserve University

Disclosures: The authors have no conflict of interest to disclose. This work has not been supported by any funding sources. This work has not been published elsewhere.

References

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