Dermatology Online Journal

Dermatology Elective Curriculum: Birdwatching List and Travel Guide
Deepa D Patadia MD¹, Eliot N Mostow MD MPH^1,2
Dermatology Online Journal 17 (6): 1

1. Northeastern Ohio University College of Medicine and Pharmacy, Rootstown, Ohio
2. Case Western Reserve University School of Medicine, Cleveland, Ohio

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Abstract

Primary care physicians often see patients with dermatologic complaints, but do not perform as well as dermatologists in the diagnoses of common dermatologic conditions. This article describes a dermatology curriculum that aims to close the clinical practice gap by providing an efficient and effective way to teach dermatology to medical students and non-dermatology residents in the setting of a busy, outpatient dermatology practice.

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Introduction

Primary care physicians spend significant time devoted to problems related to the skin (4.1% of all the time spent in outpatient care for internists, 6.2% for family physicians, and 8.1% for pediatricians) and they are often the first physicians to see patients with dermatologic complaints [1]. As such, they have the opportunity to diagnose and manage a variety of dermatologic problems. However, non-dermatologists do not perform as well as dermatologists in the diagnosis of common dermatologic conditions [2]. Furthermore, medical students and primary care residents are not uniformly permitted time to work directly with dermatologists. Many of them will have between zero and 160 hours of direct time in a dermatology clinic, compared to the roughly 4,410 hours that dermatology residents spend during their three years of training (assuming 40 hour work weeks, 75% of time devoted to clinical care, and 3 weeks of vacation). Because educational interventions can be effective in improving primary care residents’ ability to diagnose skin cancers, this represents a potentially correctable clinical practice gap that needs to be addressed [3]. This paper discusses a focused approach to closing that gap by using two analogies: a birdwatching list and a travel guide.

Whereas the need to improve dermatology education for medical students and non-dermatology residents is apparent, there are very few educational tools available specifically to guide the teaching of non-dermatologists by dermatologists. One resource aimed at medical student education is the online AAD Dermatologic Core Curriculum for Medical Students [4]. Formatted like a textbook, this provides a useful independent reading course for students. However, it is not designed for the “bedside” learning that occurs on a clinical rotation. The authors seek to close the clinical practice gap by providing an efficient and effective method to teach dermatology to medical students and residents in the setting of a busy, outpatient dermatology practice.

Curriculum

A dermatology curriculum was created to address the needs of rotating medical students and residents. The curriculum is a pocket-sized booklet that guides the learner through his or her time in the dermatology office and documents the experience. The learning objectives identified in the curriculum are designed to meet the ACGME competencies that residency programs are required to address in their curricula and evaluations: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice [5].

Using a combination of experiential and self-directed learning, as well as didactics and self-reflection, the guide is designed to focus both the preceptor and trainee on dermatologic knowledge and skills that will be useful to a primary care physician. The overall format is that of a workbook, using a framework we call a “birdwatching list” and “travel guide.” Reading materials are suggested, but learners are encouraged to identify additional resources that might be available through their preceptor and academic affiliation. Learners are expected to utilize the workbook as they see patients in the clinic. The intent is to encourage active, engaged learning on the part of the medical student or resident.

Birdwatching list

Figure 1
Dermatology Birdwatching List and Travel Guide

The bulk of the booklet consists of the “birdwatching list” (see attached document “Dermatology Birdwatching List and Travel Guide”). This is a list of conditions that the learner may see clinically during his or her rotation. Just as birdwatchers use lists to keep track of the species identified, the rotating student or resident will use the list to record conditions that he or she has seen. The list is organized into three groups: “must see,” “good to see,” and “bonus diagnoses.” The concept is expanded to include space for the learner to write notes regarding the appearance of the lesion, treatment, and other pertinent information. When completed diligently, the final list serves both as a study guide and a record of the dermatology training experience. It also provides a benchmark for evaluation of the effectiveness of the time spent with the dermatologist.

Travel guide

The “birdwatching list” is a useful tool for medical students or residents to describe all that they see; however, in most practices, the learner would need to spend considerable time (likely one week or more) in the dermatology office to see many of the items on the list. Because learners spend varying amounts of time in the dermatology office, the “travel guide” concept was created. If travelers have four hours in Paris, they are likely to go see the Eiffel Tower. If they have a day in Paris, they will not only see the Eiffel Tower, but also the Louvre! If they have a month, they might explore outlying areas and otherwise overlooked neighborhoods. Likewise, the goals of students and residents who are in the office for a half-day differ from those of learners completing an elective month in dermatology.

The “travel guide” helps the preceptor meet the challenge of teaching students and residents who will spend different amounts of time in the office by defining specific goals for each time period. For example, the resident who has a half-day dermatology experience should learn to focus on pigmented lesions and the clinical signs of malignant melanoma. With that simple goal, the preceptor and trainee have a focus that might ultimately result in an earlier cancer diagnosis and improved patient care. As the time period that the learner spends in the dermatology office lengthens, he or she will see additional diagnoses and gain additional skills: expanded differential diagnosis, regional dermatology, treatment options, and skin signs of systemic disease. The “travel guide” thus provides clear, effective objectives for the dermatology experience.

Ethics

As in every other medical field, ethical issues are encountered in dermatology on a regular basis. The ACGME recognizes “professionalism,” including ethics, as one of its competency areas for residency training [5]. The proposed dermatology curriculum includes an ethics assignment for the student or resident to complete. The learner is asked to choose an ethical issue that he or she faced in the outpatient dermatology setting, identify the bioethical principles that are in conflict, and discuss the course of action that he or she would take. The exercise is intended to be a discussion between learner and preceptor that fosters the development of critical thinking and reasoning skills. It also provides a forum in which the learner may candidly discuss difficult bioethics questions with a more experienced clinician. Anecdotally, such ethics discussions have been beneficial to the professional development of learners in the outpatient office [6].

Additional resources

The end of the workbook contains resources that may be useful to medical students or residents as they complete their dermatology rotation. These include reviews of melanoma staging, ulcers, and ulcer staging as well as information about commonly used topical steroids and antifungal agents. Because drug choice varies from practice to practice, examples of agents in each class are given and space is provided for the learner to write in additional agents that are used. Once again, the goal is to encourage active learning and provide a resource that may be relevant to his or her medical practice.

Evaluations

Figure 2
Dermatology Birdwatching List and Travel Guide Evaluations

The curriculum calls for an evaluation to occur twice during the dermatology experience: once when the learner is half-way through the rotation and once at the end of the rotation (see attached document “Dermatology Birdwatching List and Travel Guide Evaluations”). These sessions are to occur as face-to-face meetings. The learner is expected to initiate the conversation by arranging times to meet with his or her preceptor. This encourages the trainee to take responsibility for his or her own learning, engage in self-reflection, and strive for improvement of skills.

Each session consists of two parts: evaluation of the learner’s performance and evaluation of the rotation. The mid-rotation evaluation asks the learner and preceptor to review the course objectives and identify areas that need improvement. The trainee’s strengths and weaknesses are to be discussed; specific goals for the remainder of the rotation and a plan to reach those goals are to be established. The learner and preceptor are also asked to look critically at the rotation itself. They are asked to evaluate how well the rotation facilitates meeting the course objectives and the learner’s goals. Suggestions for improvement of the rotation are to be elicited from the learner. The final evaluation follows a similar format with several unique components including assessment of the learner’s progress toward goals set during the mid-rotation session and a count of items from the “birdwatching list” that were seen during the course of the rotation.

Performing two face-to-face evaluations for each learner requires a greater time commitment than filling out the typical “checkbox” evaluations that are often used for medical student and resident evaluations, but it can be done efficiently. It is expected that by performing a mid-rotation evaluation, any deficiencies that are recognized can be corrected, resulting in a more productive rotation for both learner and preceptor. Furthermore, the open-ended format of the evaluation sheet encourages discussion and goal-setting in addition to establishing competency.

Future directions

It is hoped that students and residents who utilize this curriculum during clinical dermatology rotations will retain the knowledge and skills that they gain and will apply them to their medical practices. Specifically, learners are expected to increase their ability to diagnose melanomas and non-melanoma skin cancers. Future research plans include tracking of data on the number and types of diagnoses seen (for both evaluation and benchmarking) and evaluating follow-up with learners to see if their clinical performance on skin diagnoses changed and was maintained. Our first goal is to develop a program to document when these “graduates” first diagnose a skin cancer on their own, although we are also interested in addressing issues related to more appropriate triage of patients with dermatologic conditions. Consistent with the concept of lifelong learning, we also hope to make regular enhancements to this curriculum based on feedback from participants and provide the material in “open source” format so that others may help in the process.

Conclusion

Dermatologists are charged with educating non-dermatology residents and medical students in the diagnosis and treatment of common dermatologic conditions within the very limited time allotted by residency and medical school curricula. They face this challenge in the setting of busy outpatient practices. It is hoped that the proposed curriculum will be a useful tool for preceptors and learners to focus on clinical dermatology education, utilizing the concepts of a travel guide and birdwatching list.

ACKNOWLEDGEMENTS: David Barzilai, MD, PhD contributed significantly to an earlier version of the curriculum that served as the basis for the current project. Thanks also to the many students and residents who have passed through the clinic as learners.

References

1. Fleischer AB, Herbert C, Feldman SR, O’Brien F. Diagnosis of Skin Disease by Nondermatologists. The American Journal of Managed Care. 2000;6:1149-1156. [PubMed]

2. Federman DG, Concato J, Kirsner RS. Comparison of Dermatologic Diagnoses by Primary Care Practitioners and Dermatologists: A Review of the Literature. Arch Fam Med. 1999;8:170-172. [PubMed]

3. Gerbert B, Bronstone A, Wolff M, Maurer T, Berger T, Pantilat S, McPhee SJ. Improving Primary Care Residents’ Proficiency in the Diagnosis of Skin Cancer. J Gen Intern Med. 1998;13:91-97. [PubMed]

4. Bolognia J, Bronin A (Editors). Dermatologic Core Curriculum for Medical Students. American Academy of Dermatology. www.aad.org/education/students/core.html. Accessed February 24, 2011. Revised 2004.

5. ACGME Board. Common Program Requirements: General Competencies. www.acgme.org/.../GeneralCompetenciesStandards21307.pdf Accessed February 23, 2011. Updated February 13, 2007.

6. Aldrich N, Mostow E. Incorporating Teaching Dermatoethics in a Busy Outpatient Clinic. Accepted for publication. Journal of the American Academy of Dermatology.

© 2011 Dermatology Online Journal