Dermatology Online Journal

The Dermatology Acting Internship
John B Stephens MD, Sharon S Raimer MD, Richard F Wagner Jr MD
Dermatology Online Journal 17 (7): 9

The University of Texas Medical Branch

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Abstract

Acting internships are an important component of modern day medical school curriculum. Several specialties outside of internal medicine now offer acting internship experiences to fourth year medical students. We have found that a dermatology acting internship is a valuable experience for fourth year medical students who are interested in pursuing a residency in dermatology. Our experience with the dermatology acting internship over the 2010-2011 academic year is described.

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Introduction

The concept of an acting internship (AI) for medical students was created to compensate for a shortage of resident physicians during World War II [1]. At that time, senior medical students were the “next in line” to assume patient care responsibilities that were often performed by residents. Since then, AIs have become required components of the curriculum for fourth year medical students at many institutions. More recently, specialties outside of internal medicine have begun to offer acting internship opportunities to senior medical students who have a particular interest in their field. These experiences often allow medical students to take on patient care responsibilities under supervision, similar to a first-year resident. Ideally, these experiences are more rigorous than those offered to students without specialty-specific ambitions and would provide greater insight into the demands of a residency in that field.

Over the past several decades, an increase in medical specialization has led to a change in the educational opportunities sought by fourth year medical students [2]. Many students who pursue residency in competitive specialties such as dermatology use their elective time for specialty exposure. Students who are potential dermatology applicants are often carefully evaluated during their dermatology elective(s) for their potential academic contributions, patient care skills, and appropriate fit into the program as a future resident. Although the wisdom and merit of this approach may certainly be questioned, many dermatology applicants now use their elective time to audition for a residency position at one or more dermatology programs.

At our institution we have developed a dermatology AI (DAI) that provides potential dermatology applicants a greater opportunity for direct patient care responsibilities than they would likely receive during a general dermatology elective. Procedure logs maintained in DAIs and student feedback have helped us evaluate the value and impact of this elective. We present our experience with this clinical rotation during the 2010-2011 academic year at our institution.

Methods

The DAI (DERU-4006) at the University of Texas Medical Branch (UTMB) is a 4-week elective offered to fourth year medical students (MS4s) with an interest in pursuing a dermatology residency. The DAI has been offered at UTMB to one MS4 since 2004 during each of the first 5 periods of each academic year, so that letters of recommendation for students taking this elective would be available by November 1st, the usual application deadline for dermatology residency programs. Hurricane Ike in 2008 forced a temporary discontinuation of the DAI at UTMB, but it resumed in 2010 in the current format. Although the UTMB dermatology AI is open to UTMB and visiting students alike, because of the preregistration priority of UTMB MS4s, historically there has not been availability for visiting students. Students are not required to have previously completed the general dermatology elective in order to take our DAI.

On the first day of each period when the DAI is offered, DAI students are provided with a list of six goals and expectations for the rotation:

1. Become familiar with the full scope of dermatology practice
   
   
2. Diagnose and treat common dermatological entities
   
   
3. Become familiar with the normal histological appearance of skin and common patterns in dermatopathology
   
   
4. Be able to recognize and manage skin diseases in seriously ill and hospitalized patients on the dermatology consult service
   
   
5. Gain experience in critically analyzing published, peer-reviewed dermatology articles and presenting them at our weekly journal club to faculty, residents and students
   
   
6. Become familiar with performing and interpreting commonly performed diagnostic tests and surgical procedures for skin diseases
   
   

(From: http://ar.utmb.edu/04-05review/bdisplay.asp?rec=499)

It is explained during student orientation that DAI students are being given the opportunity to perform at the level of a first year dermatology resident. In clinic, AI students see patients by themselves and check out directly to faculty. Once students are properly trained, they are allowed to perform basic procedures and bedside tests with appropriate supervision. Students are scheduled to spend two days on the Mohs surgery service and two mornings signing out cases with our dermatopathologists. In addition, they accompany a second year dermatology resident to see several hospital consults during the four-week period.

In addition to clinical responsibilities, DAI students are asked to attend all resident textbook, dermatopathology, Kodachrome, and teaching conferences (approximately 6 hours per week). Students are also expected to present at least one article during weekly dermatology journal club. On their final day, DAI students are asked to give a short presentation to the department regarding a dermatology related topic of their choice. In contrast to students on the general dermatology elective, DAI students are not given a final exam and are evaluated primarily on their clinical performance.

To assist in the evaluation of their experiences, DAI students are asked to document the number of seven different dermatology specific procedures, tests, and examinations that they performed over the four week elective. These include liquid nitrogen destruction, injection of local anesthesia, tangential biopsy, punch biopsy, suture placement, bedside diagnostic slide testing (KOH, mineral oil, Tzanck), and full body skin exams. Students keep a log detailing each required procedure that they perform and are asked to record its date. Procedures are counted only if the student performed all components of the activity. On their final day, students are also asked to complete evaluations for this elective regarding their overall educational experience. The evaluation consists of eight statements that students rate using a five-point Likert scale. A score of 1 represents “completely disagree” and a score of 5 represents “completely agree.” Student comments about the DAI are also requested at that time.

Results

All five DAI students completed the four-week elective without any problems or scheduling conflicts. Procedure logs and evaluations were collected from all five students. The students did not report any barriers regarding access to patient care responsibilities. Procedure log results are summarized in Table 1. Course evaluations by participating MS4s are summarized in Table 2.

Discussion

Acting internships are an evolving entity in medical education and are now offered in several medical specialties outside of internal medicine. Ideally, AI students should have the opportunity to expand their knowledge and clinical skills, while also developing a greater sense of professional responsibility and autonomy [2]. The Medical School Objectives Project, a creation of the America Association of Medical Colleges, recommends that medical students be able “to skillfully perform those diagnostic procedures warranted by their patients’ conditions and for which they have been trained [3].” For students interested in dermatology, such routine procedures would include liquid nitrogen destruction, injection of local anesthetic, skin biopsies, point of care diagnostic testing, suture placement, and full body skin exams. Our DAI students were able to perform each of these procedures several times and complete them with a high level of skill by the end of their rotation. As evidenced by their survey responses, the DAI students also felt confident in their ability to perform these patient care functions. All five of these MS4s subsequently matched into dermatology residency programs through the National Resident Matching Program (NRMP) in 2011, one of them with us.

Acting internships in dermatology can serve many functions for those departments and divisions that choose to offer such a rotation. First, DAI students are typically exposed to a more comprehensive experience and gain greater insight into dermatology residency than those students taking the general dermatology elective. Second, medical students value rotations in which they are actively involved in patient care and procedures [4, 5]. If the trend towards specialization in medicine continues, medical students will likely be offered a greater number of AI opportunities from many different specialties. Assuming students pursue residency in areas in which they have meaningful experiences in medical school, dermatology programs could lose potential applicants to specialties that offer an acting internship experience. Finally, several authors have commented on the limited exposure to dermatology at most medical schools [6, 7]. By offering a DAI for those students interested in dermatology, departments and divisions will create additional availability in their general dermatology elective that would otherwise have been filled by the DAI students. Although DAI opportunities were not commonly identified in a 2009 survey of dermatology electives [8], our positive experience with this educational program may encourage other dermatology departments and divisions to initiate similar DAIs as part of their dermatology elective offerings.

Conclusion

Based on our experience with an acting internship in dermatology, we recommend the DAI as a valuable educational experience for those students with a career interest in dermatology.

References

1. Ludmerer K. Time to heal: American Medical Education from the Turn of the Century to the Era of Managed Care. New York: Oxford University Press, 2005.

2. Fagan MJ, Curry RH, Gallagher SJ. The evolving role of the acting internship in the medical School curriculum. Am J Med 1998 May;104:409-12. [PubMed]

3. The Medical School Objectives Writing Group. Learning objectives for medical school education – guidelines for medical schools: report I of the medical school objectives project. Acad Med 1999 Jan;74:13-8. [PubMed]

4. Burge SM. Teaching dermatology. Clin Exp Dermatol 2004 Mar;29(2):206-10. [PubMed]

5. Burge SM. Learning dermatology. Clin Exp Dermatol 2004 May;29(3):337-40. [PubMed]

6. Hansra NK, O’Sullivan P, Chen CL, Berger T. Medical school dermatology curriculum: Are we adequately preparing primary care physicians?. J Am Acad Dermatol 2009 July;61:23-9. [PubMed]

7. McCleskey PE, Gilson RT, DeVillez RL. Medical student core curriculum in dermatology survey. J Am Acad Dermatol 2009 July;61:30-5. [PubMed]

8. Philips RC, Dhingra N, Uchida T, Wagner RF Jr. The “away” dermatology elective for visiting medical students: Educational opportunities and barriers. Dermatology Online Journal 2009 Oct 15; 15(10):1. [PubMed]

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